
GoipghtN" 10 i i 



COPYRIGHT DEPOSm 



DISEASES 

OP 



IIFAITS AID CHILDREI 



BY 

HENRY DWIGHT CHAPIN, A. M., M. D. 

PROFBSSOR OF DISEASES OF CHlt,DRBN, NE'W TOKK POST-GKADUATE MEDICAI- SCHOOl, AND HOSPITAL; 
SUPERVISING PHYSICIAN OF THE CHILDREN'S DBPARTMENTj NEW YORK: POST GRADUATE HOS- 
PITAL; ATTENDING PHTSICIAN AT -VVILLARD PARKER AND RIVERSIDE HOSPITALS; 
CONSULTtNG PHYSICrAN TO THE RAVDALL'S ISLAND HOSPITAL; TO ST. AGNES 
HOSPITAL, WHITE PLAINS, TO CONVALESCENT HOME FOR CHILDREN, 
SEA CLIFF, AND TO THE HACKENSACK HOSPITAL; PRESIDENT 
OF THE AMERICAN PEDIATRIC SOCIETY (l910-ll) 

AND 

GODFREY ROGER PISEK, M. D. 

PROFESSOR OF DISEASES OF CHILDREN, UNIVERSITY OF VERMONT; ADJUNCT PROFESSOR OF DISEASES 
OF CHILDREN AND ATTENDING PHYSICIAN TO THE NEW YORK POST-GRADUATE MEDICAL 
SCHOOL AND HOSPITAL; VISITING PEDIATRIST TO THE NEW YORK RED CROSS 
HOSPITAL; ADJUNCT ATTENDING PHYSICIAN TO THE -NVILLARD 
PARKER AND RIVERSIDE HOSPITALS; ATTENDING PHYSI- 
CIAN TO THE DARRACH HOME FOR CHILDREN 'S, 



SECOND EDITION, REVISED. WITH 181 ILLUSTRATIONS 
AND ELEVEN COLORED PLATES 



NEW YORK 

WILLIAM WOOD AND COMPANY 

MDCCCCXI 



Nr- 



Copyright, 191 1 
By WILLIAM WOOD AND COMPANY 



CCI.A'-ai)73Gl 



TO 

THE STUDENTS 

BOTH GRADUATE AND UNDERGRADUATE 

IN THE 

UNITED STATES AND CANADA 

WHOM IT HAS BEEN OUR PLEASURE TO TEACH 

THIS 

BOOK IS DEDICATED. 



PREFACE TO THE SECOND EDITION 



The authors feel gratified at the favorable reception accorded to 
this work by students and the profession at large. A book as compact 
as is consistent with thoroughness and completeness has been recog- 
nized as a distinct need, and this has been proven by the increasing 
demand for a work of this character. 

In this second edition we have incorporated all new and practical 
matters that can be of service in the field of children's diseases. The 
treatment of special diseases by vaccines, especially the autogenous, 
has been exemplified and made as practical as possible. A table of 
dosage for the use of the vaccines has been prepared. Syphilis in its 
relation to the Wassermann test and the new arsenic therapy has been 
discussed, with a view of making their application as plain as possible: 
All the recent advances in pediatrics that do not readily come to the 
notice of the profession in general have been noted. It has not been 
thought well to enlarge the work to any great degree thereby keeping 
it readily accessible for frequent reference. 

Special thanks are due to Dr. M. C. Pease for his aid in revising 
the chapter on special tests and to the publishers for their unfailing 
courtesy in the preparation of this new edition. 

H. D. C— G. R. P. 

New York, 1911. 



PREFACE TO THE FIRST EDITION 



This volume has been written by teachers who feel that a large 
contact with students has made them fairly familiar with their needs. 
Probably the first requirement at present is to bring each branch of 
medicine into as compact a form as is consistent with a thorough 
presentation of the subject. Our aim has been to accomplish this 
with pediatrics. To many, the diagnosis and treatment of diseases 
of infants and children are most perplexing. These difficulties can 
only be overcome by first sharply differentiating the anatomical and 
physiological peculiarities of the infant and child, and then consider- 
ing their practical bearings. 

The student must be familiarized with all the more recent tests, 
as well as the older practical bedside experience, in the study of 
disease. He will then, by a systematic examination of the patient, 
be able to make a scientific diagnosis. He must also be taught to 
treat rationally and with a distinct purpose in mind. We have aimed 
to present the subject in this way, and thus to make the work as 
practical as possible. The physician needs such a description of 
disease as he will actually encounter at the bedside. Where pictures 
can serve as a type, we have used illustrations, most of which are 
original. Theory and pathology have only been considered in so far 
as may be necessary to an understanding of the diagnosis, course and 
treatment of disease We have tried to take a middle course between 
the compendium, which is usually unsatisfactory, and a too exhaust- 
ive work, which, by dwelling over much on theory and exceptions, 
tends to confuse the reader. 

Our thanks are due to our hospital assistants, Drs. Dennett and 
Albee, for their help during the progress of the work. While a book 
of this sort must be indebted to all the workers in pediatrics, whom 
we have freely consulted, our personal experience at the Infants' and 
Children's Wards of the New York Post-Graduate Hospital, and in 
private practice, has formed the essential basis of our description of 
the diseases and their treatment. 

Our thanks are due to the publishers for their care and courtesy 
in the preparation of the book. 

The Authors. 

New York, September, 1909. 

vii 



CONTENTS 



SECTION I. 

The Newly-borx. 



CHAPTER I. 

Page 

The Management and Care of Premature Infants 1 

CHAPTER II. 

Injuries During Birth. 

Deformities of Head; Caput Succedaneum; Cephalhematoma; Injuries to 
Bone and Muscle; Birth Palsies; Facial Paralysis; Upper-arm Paralysis 
(Duchennes); Central Paralysis; Asphyxia; Congenital Atelectasis; 
Fetal Death 6 

CHAPTER III. 

Diseases of the Xewly-born. 

Acute Infectious Diseases; Sepsis of the Newly-born; Umbihcal Hemor- 
rhage; Umbilical Vegetations; Umbilical Hernia; Epidemic Hemoglobin- 
uria (Winckel's Disease); Fatty Degeneration of the Newly-born (Buhl's 
Disease); Icterus Neonatorum; Tetanus Neonatorum; Conjunctivitis; 
Ophthalmia Neonatorum; Mastitis; Spontaneous Hemorrhages in the 
Newly-born 14 

SECTION XL 

Hygiene op^ Infancy. 



CHAPTER IV. 

Hygiene of Infancy. 

Clothing; The Nursery; Bathing; Exercise and Fresh Air; General Habits. . 25 

CHAPTER V. 

Weight and Development. 

Weight; Length; General Shape; Head; Brain; Spine; Glands; Stomach; 
Intestines and Liver; Bladder; Muscles; Dentition; Delayed Dentition; 
Disturbances of Dentition; Care of Temporary Teeth; Permanent Teeth; 
Hutchinson's Teeth; Growth during Childhood; Mental and Moral 
Growth; Adolescence 28 

ix 



CONTENTS. 

SECTION III. 

The Examination of the Sick Child. 



CHAPTER VI. 

The Examination of the Sick Child. 

Page 
History; Inspection; Palpation; Auscultation; Percussion; Mensuration; 

Rectal Examination 41 

CHAPTER VII. 

Special Examinations. 
Exudates; The Sputum; The Gastric Contents; The Feces; The Cerebrospinal 
Fluid; Technic for Subdural or Lumbar Puncture; Technic for Aspiration 
of Pleural Cavity; The Urine; Test for Indican; Thread Reaction in 
Pyelitis; Transudates and Exudates; The Roentgen Rays; Hemoglobin; 
Red and White Blood Counts; Red Cell Count in Early Life; White Cell 
Count; Blood Smears; Nucleated Red Cells in Infants; The Relation of 
Neutrophiles to Lymphocytes during Childhood; Eosinophilia; Malaria; 
Widal Test; Tubercuhn Tests; The Wassermann and Noguchi Reaction; 
Syphilis and the Wassermann Reaction 51 

CHAPTER VIIL 
Signs of Illness in Infancy. 
Irritability of Temper; Restless Sleep; Changes in Features; State of the 

Discharges 73 

CHAPTER IX. 

General Therapeutics. 
Drug Administration; Table of Average Doses; Introductory Remarks; 
Psychotherapy; Aerotherapy; Hydrotherapy; Nasopharyngeal Toilet; 
Lavage; Enteroclysis; Gavage; Rectal Feeding; Vaccine Therapy; 
Exercises 76 

CHAPTER X. 

Suggestive Scheme for Diagnosis. 
Head; Neck; Face; Mouth; Swallowing; Abnormalities in Breathing; Chest; 
Abdomen; Inguinal Region; Delayed Growth; Hemorrhages; Extrem- 
ities 108 

SECTION IV. 
Infant-Feeding. 



CHAPTER XI. 
The Infant from the Nutritional Standpoint. 
The Infant; Life Divided into two Nutritive Periods; Essential Unity of 
Foods; Foods of the First Nutritive Period; The Infant a Mammary 



CONTENTS. XI 

Page 
Fetus; Breast Secretions; Specialized Foods; Composition and Properties 
of Breast Secretions; Comparative Anatomy and Physiology of Digestive 
Organs; Comparative Mammary Secretions; Chemical and Biological 
Standards 108 

CHAPTER XII. 

Breast-feeding, 
Importance of; Preparation for Maternal Feeding; Management; Regularity; 
Milk Agrees; Flow Scanty; Elimination of Drugs and Excretory Products 
in Milk; Milk Plentiful but Disagrees with Infant; Examination of Breast 
Milk; Nursing not Possible; Contraindications for Nursing; Weaning and 
Mixed Feeding; Selection of Wet Nurse 119 

CHAPTER XIII. 
Principles of Substitute Feeding. 
Difficulties Encountered; Principles that Apply to All Infants; Many Forms 

of Proteins, Fats and Carbohydrates 129 

CH.APTER XIV. 
Materials Used in Substitute Feeding. 
Cow's Milk: One Cow's Milk; Influence of Breed on Composition; Bacteri- 
ology of; Production of Sanitary Milk; Market Milk; Pasteurized and 
Sterilized Milk; Composition of Market Milk; Cream; Condensed Milk; 
Evaporated Milk. Cereals: General Properties of Carbohydrates of 
Cereals. Eggs: Proprietary Infant Foods; Classification of; Analyses of. . 132 

CHAPTER XV. 
Rise and Development of Scientific Infant-Feeding. 
Historical; Fundamental Errors Made; Classification of Methods of Modifying 
Milk; Laboratory Demonstrations to Illustrate Effects of Methods of 
Modifying Milk; Infants tend to adapt themselves to their Food; Infants 
differ in digestion and assimilation efficiency; Assimilation most Efficient 
in Early Infancy 145 

CHAPTER XVI. 

Practical Feeding. 
Basis of; Percentage Milk Mixtures; Top Milk; Percentage Cereal Gruels; 
Composition of Milk and Gruel Mixtures; Outline of Feeding Directions; 
Food for Healthy Infants; Directions for Making Gruels; Adaptation of 
Food to Infant; Food for Infants Previously Badly Fed; Feeding History; 
Management; Food for Infants of Feeble Constitution; A Wet Nurse 
Unobtainable; Food for the Acutely 111; Management of Cases when All 
Attempts at Adding Fresh Milk Fail; Laboratory Feeding; Calorie 
Feeding; Directions for Mother and Nurse; How to Interpret Results; 
Feeding in Hot Weather; Feeding when Traveling; Feeding when Away 
from Home; Feeding Among the Poor; Infant's Food Dispensaries; 
Making Feedings on a Large Scale; Making Food at the Feeding Stations; 
Home Modification of Whole Milk; Catalyzers 155 



Xll CONTENTS. 

CHAPTER XVII. 

Diet During the Second Year. 

Page 
Dietary Twelfth to Eighteenth Months; Eighteenth to Twenty-fourth Months; 
Two to Three Years; Diet List for Children's Hospitals; Diet Lists for 
Day Nurseries and Creches; Diet During Later Childhood 195 

SECTION V. 

Diseases of the Digestive System. 



CHAPTER XVIII. 
Diseases of the Mouth. 
General Considerations; Desquamative Glossitis; Simple Stomatitis; Aphthous 
Stomatitis; Bednar's Aphthae; Perleche; Mycotic Stomatitis (Thrush); 
Ulcerous Stomatitis; Gangrenous Stomatitis (Noma); Elongated Uvula. 202 

CHAPTER XIX. 

Diseases of the Digestive Tract. 
Corrosive Esophagitis; Congenital Occlusion of the Esophagus; Acute Gastric 
Indigestion (Acute Gastritis); Gastric Ulcer; Chronic Gastritis; Dilatation 
of the Stomach; Stenosis of the Pyloris and Pyloric Spasm; Recurrent or 
Cyclic Vomiting; Infant's Stools; Colic; Acute Gastroenteritis; Acute 
Enterocolitis; Chronic Gastrointestinal Indigestion; Congenital Dilata- 
tion of the Colon (Hirschprung's Disease); Cholera Infantum; Constipa- 
tion; Amebic Dysentery 210 

CHAPTER XX. 

The Animal Parasites. 
Parasitic Protozoa; Oxyuris Vermicularis; Ascaris Lumbricoides; Tenia 

Mediocanellata; Tenia Solium; Uncinaria Duodenalis; Trichina Spiralis. 235 

CHAPTER XXI. 
Diseases of the Liver. 
The Liver; Examination of the Liver; Jaundice; Inflammation of the Biliary 
Ducts; Inflammation of the Portal Vein; Congestion of the Liver; Fatty 
Liver; Amyloid Liver; Cirrhosis of the Liver; Abscess of the Liver 243 

SECTION VI. 

The Infectious Diseases. 



CHAPTER XXII. 

The Infectious Diseases. 
Measles; German Measles; Scarlet Fever; Variola; Vaccination; Varicella; 
Table of Exanthemata; Diphtheria; Pertussis; Mumps; Typhoid Fever; 
Influenza; Syphilis; Cerebrospinal Meningitis; Anterior Poliomyelitis; 
Epidemic Paralysis in Children; Acute Articular Rheumatism; Chronic 
Articular Rheumatism; Malaria (Paludism) Erysipelas 249 



CONTENTS. XIU 

CHAPTER XXIII. 

Page 
Disinfectants; Disinfection 337 

CHAPTER XXIV. 

Tuberculosis. 

Etiology; Tuberculous Adenitis; Thoracic Tuberculosis in Children; Pul- 
monary Tuberculosis (Acute and Chronic); Acute Miliary Tuberculosis; 
Tuberculous Meningitis; Tuberculous Peritonitis; Tuberculosis of Bones 
and Joints; Tuberculosis of the Vertebrae; Tuberculous Disease of the 
Hip; Tuberculous Disease of the Knee; Treatment of Tuberculosis in 
General 341 

SECTION VII.- 

Diseases of the Respiratory Tract. 



CHAPTER XXV. 

Diseases of the Upper Respiratory Tract. 

Acute Rhinitis; Epistaxis; Foreign Bodies in the Nose; Examination of the 
Infant's Throat; Pharyngitis and Tonsillitis in Infants; Acute Pharyngi- 
tis; Acute Follicular Tonsillitis; Ulcero-membranous Tonsillitis (Vin- 
cent's Angina); Chronic Tonsillar Hypertrophy; Adenoids; Peritonsillar 
Abscess; Retropharyngeal Abscess; Acute Laryngitis (Spasmodic Croup); 
Edema of the Glottis; Laryngismus Stridulus; Congenital Laryngeal 
Stridor; New Growths in Larynx 336 

CHAPTER XXVI. 
Diseases of the Luxgs and Pleura. 

Acute Bronchitis; Chronic Bronchitis; Pulmonary Collapse; Emphysema; 
Bronchial Asthma; Acute Bronchopneumonia; Hypostatic Pneumonia; 
Lobar Pneumonia; Pleurisy, Dry, Serofibrinous; Empyema; Pneu- 
mothorax; Pulmonary Abscess; Gangrene of the Lung; Bronchiectasis; 
Foreign Bodies in the Respiratory Tract; Subphrenic Abscess 384 

SECTION VIII. 

Diseases of the Circulatory System. 



CHAPTER XXVII. 

Diseases of the Heart. 

The Heart; Congenital Heart Disease (Cyanosis); Endocarditis; Septic 

Endocarditis Myocarditis 407 



XIV CONTENTS. 

CHAPTER XXVIII. 

Chronic Valvular Disease. 

Page 
Mitral Regurgitation; Mitral Obstruction; Aortic Obstruction; Aortic Regur- 
gitation; Tricuspid Regurgitation; Functional Cardiac Disorders. . . . 414 

CHAPTER XXIX. 
Diseases of the Pericardium 420 

SECTION IX. 

Diseases of the Blood and Ductless Glands. 



CHAPTER XXX. 

Diseases of the Blood. 

Glossary; The Blood; Anemia; Simple or Secondary Anemia; Chlorosis; 
Pernicious Anemia; Leukemia; Pseudo-leukemia of Infants (von Jaksch's 
Anemia); Table of Anemias; Treatment of the Anemias; Purpura; 
Purpura Simplex; Purpura Hemorrhagica; Henoch's Purpura; Schonlein's 
Purpura; Hemophilia 423 

CHAPTER XXXI. 

Diseases of the Ductless Glands. 

The Thymus; Enlargement of the Thymus; Status Lymphaticus; Diseases 
of the Spleen; Inflammation of the Spleen; Chronic Passive Congestion of 
the Spleen; Disorders of the Adrenals; Addison's Disease; Hodgkin's 
Disease (Lymphadenoma) ; Acute Adenitis; Chronic Adenitis; Exophthal- 
mic Goitre; Achondroplasia; Infantilism; Cretinism 439 

SECTION X. 

General Diseases of Nutrition. 



CHAPTER XXXII. 

Nutritional Disorders. 
Rachitis; Congenital Rachitis; Scorbutus; Marasmus; Diabetes Mellitus. . . 456 

SECTION XL 

Diseases of the Uropoietic System. 



CHAPTER XXXIII. 

Diseases of the Urine and Kidneys. 

The Urine in Infancy; Character of the Urine; Formation of the Kidney; 
Anuria; Polyuria; Diabetes Insipidus; Renal Calculi; Hematuria; Heme- 



COXTENTS. XV 

Page 
globinuria; Functional Albuminuria (Cyclic or Physiologic Albuminuria); 
Indicanuria; Acetonuria and Diacetonuria; Congestion of the Kidney; 
Chronic Congestion (Passive Hyperemia) of Kidney; Nephritis, Acute, 
Chronic; Pyelitis; Perinephritis; Tumors of the Kidney; Hydronephrosis; 
Enuresis 470 

SECTION XII. 
Diseases of the Genital Organs and Bladder. 



CHAPTER XXXIV. 

Diseases of the Genital Organs. 

Phimosis and Paraphimosis; Balanitis; Urethritis; Vulvovaginitis, Mastur- 
bation; Hydrocele; Undescended Testicle: Differential Diagnosis of 
Swellings in the Inguinal Region 497 

CHAPTER XXXV. 

Diseases of the Bladder. 
Cystitis; Vesical Spasm; Vesical Calculus , , o . . . 505 

SECTION XIII. 

Diseases of the Nervous System. 



CHAPTER XXXVI. 

General Nervous Diseases. 

General Considerations; Paralysis in General; Characteristics of the Various 
Types; Convulsions; Chorea; Hysteria; Epilepsy; Headaches (Migraine); 
Insomnia; Pavor Xocturnus; Tetany; Congenital Myotonia (Thomsen's 
Disease); Paramyoclonus Multiplex; Angioneurotic Edema; Tics. . . . 507 

CHAPTER XXXVII. 

Diseases of the Peripheral Nerves. 
Multiple Neuritis; Diphtheritic Paralysis; Facial Paralysis 528 

CHAPTER XXXVIII. 

Diseases of the Spinal Cord. 

Myelitis; Multiple Sclerosis; Hereditary Ataxia (Friedrich's Disease); Primary 

Myopathies 532 

CHAPTER XXXIX. 

Diseases of the Brain. 

Meningitis; Encephalitis; Abscess of the Brain; Tumors of the Brain; Cerebral 
Palsies; Hydrocephalus; Microcephalus; Idiocy; Imbecility; Feeble- 
mindedness; Mongohan Idiocv; Amaurotic Familv Idiocv 543 



XVI CONTENTS. 

SECTION XIV. 
Congenital Malformations and Deformities. 



CHAPTER XL. 

Congenital Malformations and Deformities. 

Page 
Tongue Tie, Hare-lip; Cleft-palate; Branchial Cysts; Malformations of the 
Esophagus; Malformations of the Rectum and Anus; Hypospadias; 
Extrophy of the Bladder; Congenital Dislocation of the Hip; Congenital 
Absence of Bones; Tahpes; Webbed Fingers and Toes; Meningocele and 
Encephalocele; Spina Bifida 560 



SECTION XV. 
The Commoner Surgical Diseases. 



CHAPTER XLI. 

The Commoner Surgical Diseases. 

Anesthesia; Hernia; Circumcision; Appendicitis; Intussusception (Including 
Intestinal Obstruction); Peritonitis, Acute, Newly-born, Early Life, 
Pneumococcic; Ascites; Ischiorectal Abscess; Rectal Polypus; Fissure of 
the Anus ; Prolapse of the Anus and Rectum ; Malignant Tumors in 
Childhood 574 



SECTION XVL 
Diseases of the Ear and Eye. 



CHAPTER XLII. 



Diseases of the Ear. 



General Consideration; Otoscopy; Otitis; Mastoiditis; Infective Cerebral 

Sinus Thrombosis . 590 



CHAPTER XLIII. 

The Commoner Diseases of the Eye, 

Foreign Bodies; Blepharitis; Conjunctivitis, Diphtheritic, Chronic, Granular; 
Chalazion; Strabismus; Keratitis; The Diagnostic Significance of Ocular 
Affections; Diagnostic Hints 595 



CONTENTS, XVll 

SECTION XVII. 

Diseases of the Skin. 



CHAPTER XLIV. 

Diseases of the Skin. 

Page 
Ichthyosis; Nevi; Dermatitis Exfoliativa Neonatorum (Ritter's Disease); 
Pemphigus Neonatorum; Impetigo Contagiosa; Seborrhea Capitis; 
Erythema Multiforme; Acute Exfoliative Dermatitis; Eczema, Acute, 
Subacute, Chronic; Psoriasis; Miliaria; Urticaria; Furunculosis; Angio- 
neurotic Edema; Herpes Zoster 600 

CHAPTER XLV. 

Parasitic Skin Diseases. 

Pediculosis; Scabies; Tinea Tonsurans; Tinea Favosa; Alopecia Areata; Ivy 

Poisoning 613 

Index 619 



DISEASES OF CHILDREN. 



SECTION I. 
THE NEWLY-BORN. 



CHAPTER I. 
THE MANAGEMENT AND CARE OF PREMATURE INFANTS. 

When a premature infant is born it is suddenly deprived of a 
very important organ, namely, the placenta, which has a selective 
action for the developing fetus. Three and sometimes four factors 
mitigate strongly against its extrauterine existence. These factors 
are in the order of their importance: (1) Undeveloped heat and 
respiratory centers; (2) increased susceptibility to infection; (3) 
patent umbilical vessels with a tendency to putrefaction; and (4) 
sometimes possible congenital disease from its progenitors. 

The temperature of a premature babe at the time of birth varies 
from 98.6° to 100° F. It is often suddenly introduced into, and 
examined in a room temperature of 74° F. ; that is, with a variation of 
24° or 26° F. A subnormal temperature undoubtedly often results, 
from which the child's undeveloped heat centers fail to assist it. A 
lowered temperature, then, is the first evil to combat. 

Brothers has shown that more than one-half of all deaths under 
four weeks are attributable to prematurity. We believe that many 
premature infants that help to swell the mortality statistics may be 
saved by timely and appropriate directions from their medical attend- 
ants. More viable under-term children are born now than formerly, 
owing to better methods at the time of birth and to such surgical 
measures as Cesarean section. The records of those born and reared 
in a maternity hospital show a high percentage saved; for example: 
Maygrier, at the Charite in Paris, has saved 516 out of 548 cases 
which weighed 4^ to 5^ pounds at birth, or a percentage of 96.58 
per cent. Voorhees, from the Sloane Maternity, has an average of 
79.5 per cent., but these cases had never been exposed to chilling 
and transportation and had the advantage of woman's milk as a 
pabulum. It must be remembered, however, that our maternity 
hospitals have no facilities for caring for outside cases, and these are 
sent after a variable time to an institution which has an incubator. 



2 DISEASES OF CHILDKEN. 

The natural solution seems to be incubator life, and this apparatus 
will maintain the body heat, if properly managed at 90° F., but it 
will also necessitate that the babe respire this superheated air, often 
vitiated and liable to germ contamination. Constant and eternal 
vigilance is required to keep the apparatus — even the best obtainable 
— in proper working order. If the temperature rises suddenly, a 
heat stroke results, and if the gas pressure falls or the wind changes, 




Fig. 1. — Incubator with outside ventilation and 
automatic regulation of temperature. 



a subnormal temperature may follow. The premature infant de- 
livered at home should therefore be placed in a padded basket 
or crib, (see Fig. 2) and surrounded with hot-water bottles or kept 
warm with an electric heater. The room must be quiet and a 
sunny one; it should be kept at 78° to 80° F., preferably heated and 
ventilated by an open fireplace. The supply of fresh air should be 
constant. If unavoidably the infant's temperature has fallen to 
subnormal, a warm bath and gentle friction are indicated before 
supplying the swaddling blankets made of cotton which are to serve 
as clothes. The importance of conserving this body heat may be 



THE :VIAXAGEMEXT AND CARE OF PRE.AIATURE INFANTS. 3 

emphasized by the statistics of Budin in France. Ninety per cent, of 
the premature infants died who had a temperature between 90° and 
92° F. 

It is a significant fact that the great majority of cases brought 
to us at the hospital had a subnormal temperature. 

The weight and length must next be considered in its relation 
to viability and to feeding. If the weight is below 2i- pounds, the 
premature are rarely saved, while those with birth weights between 
2^ and 5 pounds are to be regarded as congenitally feeble. The 




Fig. 2. — Padded basket-crib suitable for premature infants. 



length of time in utero is, however, of greater importance than the 
birth weight in estabhshing the prognosis. Moore saved a premature 
infant born at the sixth month of gestation which was nine inches 
long and weighed one and one-half pounds (this babe w^eighed 19 
pounds at the end of fifteen months). Therefore, if the child is born 
alive, it should be given every chance to live. The obstetrician should 
immediately place the babe in a warmed blanket or in warm cotton 
wool and have hot bottles close to its body and beneath it. Swad- 
dling clothes are later used. 

The next problem will be that of nutrition. An undeveloped 
digestive tract with a minimum amount of secretions and an over- 
active liver will demand careful consideration. The breast milk of a 
woman whose child is about ten days old is the ideal food; this should 
be diluted with water three times in the beginning, and later twice, 
and finally undiluted breast milk is allowed, especially if the infant 
is strong enough to suck. The quantity given should approximate 



DISEASES OF CHILDREN. 



1 



one-fifth of the baby's weight, if it is above four and a half pounds; 
but very small amounts, one dram every hour, should be ordered for 
the first few days, and very gradually increased. 

The mother's own milk should be pumped, mas- 
saged, or nursed out by another stronger child, but 
should not be used for a week or ten days, as the 
colostrum at this period of gesta- 
tion, as shown by Adriance, is too 
rich in proteins. A wet nurse for 
a short period or a small amount 
of breast milk (often one ounce will 
suffice for twenty-four hours) 
should be otherwise obtained. If 
this is impossible, a 4 per cent, 
lactose solution is fed for a few 
days, followed by plain whey, and 
then dram-feedings of modified 
milk, beginning with 0.5 per cent, 
fat, 0.25 per cent, proteins, and 4 
per cent, sugar are given, gradually 
increasing the proteins to 0.4 per 
cent, and later to 0.8 per cent. 
Sodium citrate, one grain to the 
ounce, will assist in modifying the 
curds. 

These small percentages are 
best obtained from the laboratories, 
or with the Deming percentage 
modifier. Peptonization is indi 
cated if the stools show feeble di 
gestion. The weaker infants ar( 
fed with a dropper, while those 
capable of making sucking efforts 
are fed with a modified Breck 
feeder. This can be made from a 
piece of glass tubing with dropper 
the one being perforated by three small holes 
4). Gavage is dangerous. We have found milk 
and bronchi of premature infants at autopsy 
which reached there via the tube. The medical attendant must not 
be discouraged to note a falling off in weight for some time. It is 
often three to four weeks before the birth weight is regained. The 



Fig. 3.— Breck 
feeder for prema- 
ture infants. 



nipples applied, 
(see Figs. 3 and 
in the trachea 



Fig. 4. — Home- 
made feeder. 



THE aiANAGEMENT AND CARE OF PREIMATURE INFANTS. 5 

nurse must be ever watchful for attacks of cyanosis, which must 
be combated with two- to five-drop doses of diluted brandy, or cam- 
phor, gr. I, in sterile olive oil hypodermatically. The icterus which 
is not uncommon and which is usually associated with constipation, 
often produces fatal results. It is best treated with one- or two- 
twentieths of calomel. 

Daily inunctions of liquid petrolatum (albolin) are given in lieu 
of baths for cleanliness after the usual diapering. After the first 
year these premature infants are not necessarily weak and puny, but 
on the contrary are often indistinguishable from the full-term infant. 
The prognosis, however, should always be considered as unfavorable, 
as the undeveloped digestive tract, the possibility of sepsis, and the 
defects in the heart all mitigate against its existence. The importance, 
however, of obtaining breast milk cannot be overestimated, for it is 
almost impossible to raise them without its help. In. our experience, 
which includes over one hundred premature cases, we prefer the open 
method of treating premature infants to the use of the incubator, and 
all kinds have been tried. If an incubator is used, only the kind 
having connection with the outside air should be emploj^ed, as these 
infants are exceedingly susceptible to a lack of fresh air. 



CHAPTER II. 
INJURIES DURING BIRTH. 

Deformity of Head. 

A certain pointing toward the occiput and elongation of the head 
are noted in most labors. This may be extreme in cases where a long 
or difficult labor has resulted in excessive molding of the presenting 
part. Fortunately, little damage is done by this distortion and the 
head usually takes on its natural shape in a few days. 

Caput Succedaneum. 

The swelling on the presenting part of the head resulting from 
pressure is known as caput succedaneum. It consists of trans- 
uded serum and extravasated blood located between the scalp and 
pericranium in the loose connective tissue of this part. It has a 
soft, boggy feeling. Prolonged or difficult labors produce this effu- 
sion from pressure on the portion of the head that presents. No 
special treatment is required, as the absorbents of the connective tissue 
will cause its disappearance within a day or so. 

Cephalhematoma. 

Cephalhematoma is an effusion of blood between the bone and 
the periosteum covering it. It usually appears within one to three 
days after birth. Its seat may be any portion of the cranial vault. 
Most commonly it occurs in the parietal region, sometimes over the 
temporal or occipital bones. The overlying integument presents no 
discoloration. A bony ring is soon developed around the base 
from the secretion of the periosteum. The effusion is, in most cases, 
limited by a suture. The effused blood, as a rule, undergoes absorp- 
tion within the first three months of life. In rare cases suppuration 
ensues, and even caries of the subjacent bone may occur. The fact 
that the tumor does not communicate with the brain cavity, which 
fact can usually be readily made out by palpation, serves to distinguish 
this affection from encephalocele. To differentiate caput succeda- 
neum and cephalhematoma it may be borne in mind that while the 
former is nonfluctuating and disappears in a few days, the latter is 

6 



INJURIES DURING BIRTH. 7 

soft and fluctuating, presenting a marginal ridge, in the center of 
which the skull is felt, and disappears in a few months. 

Treatment. — In most cases no treatment is called for. Should 
the tumor grow it may be strapped with adhesive plaster, the head 
first being shaved. Incision, while generally condemned, has been 
practised with success. It offers the advantage of immediate relief 
and leaves no permanent deformity. The effused blood can usually 
be removed through a small opening. A firm compress is worn for 
several days to prevent refilling. It is needless to say that the strictest 
asepsis must be observed. If suppuration occurs the usual surgical 
treatment of abscess must be carried out. 

Injuries to Bone and Muscle. 

(a) Bone. — The soft and partially developed condition of in- 
fantile bone renders it liable to injury if subjected to much mechan- 
ical violence during delivery. The cranial bones are especially 
liable to indentation and fracture when the forceps is employed, yet 
such accidents may occur in spontaneous labor. Fracture of the cra- 
nial bones is most frequent in the parietals. When the brain is not 
injured the fracture is not apt to result seriously. Rupture of intra- 
cranial blood-vessels may lead to fatal hemorrhage. Simple inden- 
tations apparently cause little if any damage to the brain structures. 
Gentle efforts at reduction may be attempted, and thus the normal 
shape be restored. Fracture of the inferior maxillary bone may 
result from traction with the fingers in unskillful delivery of the after- 
coming head in breech presentations. Injuries may be inflicted 
upon the vertebrse or the spinal cord, with resulting paraplegia, and 
they are almost invariably fatal. Fracture of the humerus not uncom- 
monly occurs in forcible delivery of the arm in breech births, or sepa- 
ration of the epiphysis from the shaft of the bone may take place. 
Fracture of the clavicle usually results from violent use of the fingers 
in extracting the after-coming head. The femur may be fractured 
from misdirected traction with fingers or fillet in breech delivery. 

{b) Muscle. — Hematoma of the sternocleidomastoid muscle may 
result from artificial interference in breech extractions. A hard 
tumor about the size of a pigeon's egg may be seen developing in this 
muscle, usually on its anterior border. It is noticed between the ages 
of one and six w^eeks, and usually disappears by absorption in a 
month or so. The muscle fibers are sometimes torn. Hematoma 
of the sternocleidomastoid may lead to contracture of the injured 
muscle and torticollis. As a rule, the blood is spontaneously ab- 
sorbed in a few weeks. 



DISEASES OF CHILDREN. 



Birth Palsies. 



Injuries to the nerves during birth may be central or peripheral. 
The latter are fortunately the most common and the usual types are 
the facial and upper-arm paralysis. 

(a) Facial Paralysis. — Pressure upon the seventh or facial 
nerve at the stylomastoid foramen by the blades of the forceps is 
usually responsible for facial paralysis. The affection is, in most 
cases, unilateral, and will not be noticed when the infant is at rest. 
When nursing or crying, the palsy of the affected side is apparent. 
Recovery usually takes place spontaneously in a few weeks. If the 
paralysis does not disappear promptly, faradism may be employed. 
In rare cases the palsy is permanent. 




Fig. 5. — Erb's paralysis. 



(6) Upper-arm Paralysis (Erb's or Duchenne's Paralysis. — ■ 
The next most frequent peripheral palsy is seen in the arm. Various 
conditions during birth may produce compression and injury of the 
nerves about the shoulder, such as severe pressure of the obstetrician's 
finger or the blunt hook in the axilla, hematoma of the sternocleido- 
mastoid, or fracture of the humerus with displacement of the frag- 
ments. The greatest number of upper-arm paralyses, generally 
known as Erb's or Duchenne's paralysis, occur after breech deliveries. 
The injury usually results from traction made upon the shoulder in 
the delivery of the head, or in bringing down the arm when it is 
found above the head or upon the head in vertex deliveries, and is 
due, as a rule, to stretching of the fifth, sixth, and seventh cervical 
nerves. Dragging the head or the trunk strongly to one side is 



INJURIES DURIXG BIRTH. 9 

usually responsible for the excessive traction upon the nerve trunks 
of the injured side. The deltoid, biceps, brachialis anticus, and supi- 
nator longus are the muscles oftenest affected. In mild cases the 
paralysis may not be noticed for some weeks, while in severe ones it 
will usually be apparent at once. 

Diagnosis. — The position of the arm is characteristic. It hangs 
helpless at the side and is rotated inward. As the triceps is not af- 
fected; the child can extend the forearm, but cannot flex it. After a 
few weeks the affected muscles show more or less atrophy, but the 
child will generally begin to use the forearm. The diagnosis of Erb's 
parah^sis is not, as a rule, difficult when seen during the first year. 
The peculiar position of the arm and the group of muscles involved are 
rarely met with in any other affection at this early age. 

Prognosis. — The prognosis will depend upon the severit}^ of the 
symptoms and the time when the treatment is begun. Spontaneous 
recovery takes place in some cases within two or three months. If 
there is but little improvement after this length of time, spontaneous 
recovery is not to be expected, and the case demands active treat- 
ment. In some cases partial paralysis may remain for several years 
or be permanent. 

Treatment should be begun as earty as the third month, and 
should consist in frictions or massage and the persistent use of elec- 
tricit}^ If the muscles react to the faradic current, it may be used; 
but if not, the galvanic current must be emjDloyed. The treatment 
must be continued for several months, or until recovery is nearly 
complete. The foregoing treatment applies also in facial paralysis. 

Central Paralysis. — Meningeal apoplexy, followed b}^ various 
paralyses, is one of the untoward results cf prolonged and difficult 
labor. This is more apt to occur with the first-born child owing to 
the unyielding character of the maternal parts. While hemiplegia 
is the rule, from the distribution of the hemorrhage over the surface 
of one side of the brain, there ma}^ be less diffused local hemorrhages 
resulting in paralysis of the face or of one arm or leg. In eleven 
autopsies following this injury, as reported by Dr. McNutt, the hemor- 
rhage was principally at the base of the brain in the vertex presen- 
tation, whereas it was largely on the convexity in the breech pres- 
entations. It has been supposed that the use of forceps is largely 
responsible for this accident, and the rough and careless use of instru- 
ments is doubtless a competent cause. The writer believes, however, 
that too long delay in the application of the forceps when the head is 
being subjected to prolonged pressure is oftener responsible for this 
unfortunate accident. The careless use of ergot before delivery, by 



10 DISEASES OF CHILDREN. 

inducing a tetanic contraction of the uterus, also favors congestion 
of the fetal brain. 

Symptoms and Prognosis. — The symptoms induced by men- 
ingeal extravasation depend, of course, upon the seat and extent of 
the effusion. The extravasation is frequently located over the motor 
convolutions, and if not extensive the hemiplegia may disappear with 
the absorption of the blood. If more extensive, however, the infant 
may be stillborn or, if living, it may soon die from asphyxia or in a 
comatose condition. The voluntary muscles in such cases may be in a 
spastic condition or, more rarely, in a state of complete relaxation. 
The respiration is more apt to be depressed and irregular than the 
pulse. Convulsions may occur shortly after birth, followed by coma. 
If death does not ensue the prognosis for the extremities affected is 
good, as the paralysis gradually improves, often undergoing complete 
recovery. The brain, however, may be irreparably injured, as shown 
by subsequent epilepsy or even by various degrees of idiocy. 

Treatment. — The treatment must be preventive. This consists 
in avoiding as much as possible prolonged pressure upon the fetal 
head, in a careful use of the forceps, and in seeing that the infant 
cries immediately after birth, thus being assured that the lungs are 
inflating. It is of great importance that the transition from the 
fetal to the post-natal circulation should at once take place at birth, 
as otherwise great damage may be done, particularly to the brain; 
the vessels here are fragile and easily ruptured. If the infant cries 
the expanding lungs draw off the excess of blood that may do damage 
elsewhere. The physician should give his first attention to the infant 
until this happens, as a short period of asphyxia may do incalculable 
harm. If the lungs do not act, it is well to let the cord bleed to the 
extent of a few drams to prevent severe congestion of other vital 
organs. 

Asphyxia. 

The accidents during labor that induce asphyxia are: sudden 
death of the mother, constant pressure upon the umbilical cord, severe 
compression of any part of the fetal body, especially the head, as 
noted above, and more or less complete detachment of the placenta. 
In consequence of the air-hunger induced by these conditions, a 
vigorous infant may by inspiratory suction take in secretions of the 
birth-canal, which may cause suffocation after birth or induce pneu- 
monia later. Very feeble infants may fail to establish respiratory 
movements after birth, owing to weak or defective muscles and nerves. 
In partial asphyxia there is congestion and suffusion of the skin, with 



INJURIES DURING BIRTH. 11 

blueness of the mucous membranes, full pulse, and moderate action 
of the reflexes. As the symptoms of carbon-dioxid poisoning become 
more marked, the pulse grows feebler, the skin paler, and the mucous 
membranes assume a grayish-blue color. The reflexes are likewise 
lost. The prognosis in the latter condition is exceedingly bad. In 
the milder degrees of birth-asphyxia recovery usually ensues. 

The Preventive Treatment consists in measures addressed to the 
acceleration of tedious labors and the prevention of prolonged pressure 
upon the fetal parts, especially the head. During descent of the head 
malpositions of the cord, especially prolapse, or winding tightly 
around the neck, must be looked for and, if possible, corrected. One 
of the possible causes of asphyxia will be removed if as soon as the 
head is born it is so turned that the face shall not lie in a pool of blood 
and liquor amnii. At the same time the mouth and fauces can hastily 
be cleaned of mucus with a moist rag drawn over the finger or by 
means of a soft rubber tube with a rubber bulb attached. In moderate 
degrees of asphyxia the stimulus of the cool external air and allowing 
a dram or two of blood to escape by the cord will be sufficient. 
Should this not suffice the chest may be sprinkled Avith cold water to 
stimulate the reflexes, while the infant is held suspended by the feet 
for the purpose of allowing mucus to gravitate from the air-passages. 
The child may be plunged alternately into hot and cold water. The 
hot water should have a temperature not exceeding 105° F. When 
these external stimuli fail to excite respiratory movements, resort 
must be had to artificial respiration. 

The child's pharynx should first be cleared of mucus and other 
liquid material that may have been drawn into it by premature 
efforts at respiration. The simplest and most effectual method 
of inflating the lungs is by direct insufflation — the mouth-to-mouth 
method. 

Direct Insufflation.— The child is placed upon its back with 
the head extended by means of a small pillow or roll of clothing 
placed under its neck; the mouth is well cleansed and a towel or hand- 
kerchief is spread over the face. With one hand closing the nose, 
and with the other making pressure upon the epigastrium, to prevent 
the inflation of the stomach, the physician forces air from his own 
gently into the child's mouth and inflates the lungs. The air is 
expelled by gentle pressure upon its chest, and the process then 
repeated. When properly performed, this method is safer than passing 
a catheter or other instrument into the trachea, as is sometimes 
practised. Care should be taken lest injury be done to the air-cells 
by too forcible expansion. 



12 DISEASES OF CHILDREN. 

Various methods of artificial respiration may be employed. 
Schultze's method is most commonly employed. The operator holds 
the infant suspended, face to the front, his index-fingers being hooked 
in the axilla?, the thumbs resting on the front of the chest and the 
fingers upon the infant's back. The lower portion of the child's body 
is now swung outward, upward, and finally toward the operator's face, 
inverting the position. Care should be taken that the trunk is most 
strongly flexed in the lumbar region. In this position the thorax 
is compressed — expiration. The child's lower extremities are now 
swung outward away from the operator's body and downward till 
the child hangs suspended by its axillae in the position first described. 
In this position of the child, hanging by its upper extremities, the 
abdominal contents fall and the diaphragm sinks — inspiration. 
To assist the respiratory movements the pressure of the operator's 
thumb is relaxed during inspiration and increased during expiration. 
This method is not to be recommended in feeble children. 

Laborde's method is easy to apply in the case of very feeble 
infants. It consists in making rhythmical traction upon the tongue, 
eight to ten times to the minute. 

After the respirations have been started, the infant must be 
watched to see that they continue. It may be advisable in some 
cases to administer hypodermatically ten to twenty drops of whisky 
combined with 1 minim of the tincture of belladonna or -g-J-o gi'ain of 
strychnin. In most cases it will be necessary after resuscitation to 
apply dry heat by a hot-water bag or other means. In asphyxia 
pallida a rectal injection of water at a temperature of 110^ F. is of 
marked service. 

Congenital Atelectasis. 

Closely allied to asphyxia, and often associated with it, is a per- 
sistence of the fetal condition of the lungs, either of one or both in 
whole or in part. It is due to failure of the infant to completely 
inflate the lungs, and may persist for a considerable time. Sometimes 
it results in death, even after respiration has apparently been fully 
established. 

This is more apt to involve the lower lobes than the upper ones. 
It is frequently seen in premature infants with feeble respiration. 
The cause may also be injury to the brain from pressure. The symp- 
toms are those of deficient respiratory action, such as pallor, feeble 
cry, and poor circulation, with very little expansion of the chest- 
walls over the affected area. Deep inspiration may be encouraged 
by artificial respiration, and the vitality conserved by the external 



INJURIES DURING BIRTH. 13 

application of heat and the judicious administration of nourishment 
and stimulants. 

Fetal Death. 

Death may take place at or before birth, which must sometimes 
be differentiated from asphyxia. In the former the heart pulsations 
cannot be felt and respirations and reflexes are absent. In the latter 
the heart is pulsating, reflexes are present, and there may be feeble 
attempts at respiration. We should not refrain from efforts at 
resuscitation because the heart-sounds are absent or no pulsations 
can be felt in the precordial region. The distinction between a dead- 
born and a still-born infant can usually be made by the rapid fall of 
rectal temperature in the former to ten or fifteen degrees below nor- 
mal and by the widely dilated condition of the pupils in the dead-born. 
In the still-born, artificial respiration may be emplo3^ed, and the hypo- 
dermatic injection of a few drops of whisky and gr. ^i-^ of sulphate 
of strychnin may be given. 



CHAPTER III 
DISEASES OF THE NEWLY-BORN. 

Acute Infectious Disease. 

While the newly-born infant seems to bear a sort of natural 
immunity to the common infectious diseases of childhood, it is pos- 
sible for an infant to be infected through the placenta before birth or 
by the usual methods soon after birth. While the symptoms of mea- 
sles, pertussis, pneumonia, scarlatina, or influenza are largely the same 
as when seen later on, the prognosis in the newly-born is bad. 

Sepsis of the Newly -born. 

An infection induced by pus-forming organisms such as the 
streptococcus pyogenes and the staphylococcus pyogenes aureus 
and albus may be seen in the newly-born. The umbilicus is the 
most vulnerable spot for the entrance of septic poisons during or 
shortly after birth. Upon ligation of the cord the blood that remains 
in the umbilical veins forms small thrombi that should gradually 
harden and in time become calcified, forming a fibrous cord in the 
same manner as in the ductus arteriosus and ductus venosus. In 
these latter structures the formation of thrombi is never accompanied 
with grave consequences, since their internal situation prevents the 
access of infectious agents. Pyogenic organisms, however, can 
readily gain access to the umbilical vein and give rise to umbilical 
phlebitis and septicemia. 

There is a constant alteration after birth in the blood-pressure in 
the umbilical vein, due to the action of the heart and lungs, by which 
a sort of flux and reflux is produced. This favors infection of the 
system when the contents of this vein become septic. 

This grave accident is liable to occur when the mother is in a 
septic condition. The poison may be produced by the same agents 
that have caused the puerperal fever. In these cases of sepsis there is 
a puriform or yellow softening of the thrombi that fill the umbihcal 
vein. The softened matter consists of pus-corpuscles and finely 
granular matter containing micrococci. This sets up an inflammation 
not only in the vessel itself, but also in the surrounding tissues. In- 

14 



DISEASES OF THE NEWLY-BORN. 15 

fective emboli may be carried to various parts of the body. As the 
micrococci enter the umbihcal vein from the umbiHcal fossa, owing 
to the perviousness of this vessel, the structures near at hand, espe- 
cially the liver, bear the first brunt of the septic inflammation. The 
latter organ is usually found much diseased or degenerated. There 
is jaundice, with constant elevation of temperature and other symp- 
toms of general septic infection. If the infant lives long enough 
peritonitis will probably develop, and sometimes empyema, pleuro- 
pneumonia or even meningitis. In all cases evidence of severe illness 
and prostration are present. Cutaneous, mucous, or visceral hemor- 
rhages may supervene at any time. The abdomen is generally swollen 
and tender, and dirty-looking pus may be seen oozing from the navel; 
slight pressure about the umbilicus will often cause pus to exude if it 
is not otherwise apparent. The fecal discharges may be of natural 
appearance, but the urine is usually highly colored. The infant refuses 
nourishment, and there may be vomiting of greenish matter. Severe 
nervous symptoms, such as convulsions or coma, supervene before 
death. While the umbilicus is the most common seat of septic infec- 
tion, any sore or abrasion elsewhere may afford entrance to germg. 
Erysipelatous eruptions on the abdomen, chest, or other parts, are 
the most frequent manifestations of such infection. 

Multiple joint inflammation and suppuration may appear as evi- 
dences of a general pyemia, and a few cases of osteomyelitis have been 
reported. 

Treatment. — The prophylactic treatment of sepsis consists in 
the careful antiseptic management of labor and proper attention and 
cleanliness in reference to the navel. Localized sepsis may be com- 
bated by the topical use of peroxid of hydrogen, bichlorid of mercury 
solution, or other strong antiseptic agents. 

The remedial treatment of systematic infection consists in full 
stimulation and general support and the judicious use of external re- 
frigerant measures. In the latter condition, however, treatment is 
generally futile. Empyema, pleuropneumonia, erysipelas and any 
other local effect of infection must be treated symptomatically. 

Umbilical Hemorrhage. 

Hemorrhage may take place from the stump of the cord shortly 
after birth from insecure ligation, from shrinkage of the funis, or from 
slipping of the ligature. Laceration of the cord between the abdomen 
and the ligature may also be responsible for hemorrhage. Secondary 
hemorrhage, usually between the fifth and fifteenth days, may occur, 



16 



DISEASES OF CHILDREN. 



even though the cord has been securely ligated and properly watchedo 
The trouble may be due to changes in the walls of the minute blood- 
vessels, allowing transudation, or to imperfect coagulability of the 
blood. In the latter case the hypogastric artery and the umbilical 

artery and vein have not 
been tightly occluded by 
the usual fibrinous plug. 
The hemorrhage is ac- 
counted for by syphilis, 
jaundice, hemophilia, or by 
depraved health on the 
part of the parents. 

Treatment. — The great 
majority of cases are fatal 
from the impossibility of 
controlling the hemorrhage. 
In the milder ones a com- 
press of gauze tightly ap- 
plied with adhesive strips 
may be sufficient. 

Adrenalin (ttoo") ^^Y 
also be used to moisten the 
compress. In the most 
obstinate cases it may be 
necessary to transfix the 
umbilicus by two needles 
placed at right angles with 
a figure-of-eight ligature 
placed tightly around them. 

Umbilical Vegetations. 

Fungous granulations 
at times appear, arising 
from the floor of the um- 
bilical fossa, shortly after 
the falling of the cord. 
They may attain the size 
of a pea, and they usually 
exude a bloody serum, which may induce excoriations in the sur- 
rounding skin. The granulations may gradually atrophy after weeks 
or months of sluggish existence. The constant moisture and dis- 
charge is, however, a source of irritation, and it is best to destroy the 




Fig. 6. — Adhesive plaster dressing for umbil- 
ical hernia, made with two pieces overlapping. 
{Pisek's method.) 



DISEASES OF THE NEWLY-BORN. 17 

growths. This can be accompHshed by repeated cauterization with 
the solid stick of nitrate of silver or, better still, by passing a ligature 
around the base of the mass and amputating the exuberant granula- 
tions with scissors. A dry dressing of boric acid or subnitrate of 
bismuth may then be applied. 



Umbilical Hernia. 

There is a tendency, especially on the part of badly-nourished in- 
fants, for the gut to protrude a little at the umbilicus. It is hence 
desirable to keep a firm abdominal binder in place for the first two 
or three months. After this time if a protrusion persists, the hernia 
may be retained by long strips of adhesive plaster. It may be necessary 
to keep up this support for several months. The dressing may be 
examined and changed every few days to be sure the pressure stays 
in the right place. If the skin is irritable from frequent pulling off of 
the strips of plaster, part of the plaster may only be removed and the 
new plaster applied over the ends of the old strips and thus tightened 
over the hernia. The skin must be kept scrupulously clean and fre- 
quently dusted with powder. In older infants, an abdominal truss 
may occasionally do good service. It is rare for this form of umbilical 
hernia to last through childhood. In exceptional cases when the rup- 
ture increases rapidly in size operative interference may be considered. 



Epidemic Hemoglobinuria. 

{WmckeVs Disease.) 

This form of hemoglobinuria is very rarely seen in the newly-born 
and then usually in institutions. It begins a few days after birth in 
healthy infants with constitutional symptoms of depression shown 
by a weak rapid pulse and general asthenia. An icterus soon develops 
that becomes very marked and is noted over the whole body. The 
urine is soon lessened in amount, contains traces of albumin and 
hemoglobin in large amounts. Casts are occasionally also found. 
The color of the urine may be dark or smoky. The disease pro- 
gresses rapidly,often terminating in one or two days. There may be 
marked cyanosis with convulsions or coma before the close of life. 
The disease is evidently an outcome of some sort of infection, but 
the microbe has not yet been isolated. Treatment does not seem 
to be of much avail. 
2 



18 DISEASES OF CHILDREN. 

Fatty Degeneration of the Newly -born. 

{BuhVs Disease.) 

This is a very rare disease that acts Uke some form of pyogenic 
infection. It is characterized by fatty degeneration of the heart, Kver, 
and kidneys with hemorrhages from any of the mucous membranes 
or into the various serous cavities or viscera. The spleen and hver 
are both usually enlarged. The disease is accompanied by great 
prostration and may last one or two weeks. Icterus may be present. 
The treatment is supporting and symptomatic, but not able to save 
life. 

Icterus Neonatorum. 

This is a common affection of the newly-born. Two distinct 
varieties are recognized, differing widely in cause and prognosis and 
known as the mild and grave forms. 

(a) Mild Form. — Two divergent theories have been advanced 
to account for this form. The first considers the jaundice to be purely 
hematic; the second theory regards it as hepatic in origin. Bile is 
first formed in the liver and then carried into the circulation, the resorp- 
tion being due either to congestion or to edema of the hepatic tissue. 
It seems highly probable that both these theories may apply in 
different instances, and doubtless many cases of icterus neonatorum 
are to be satisfactorily explained only by taking into consideration a 
morbid condition of both the blood and the liver, thus combining the 
hematic and hepatic theories. 

The intense congestion of the skin observed during the first few 
hours of life often produces a yellowish coloration that cannot be con- 
sidered jaundice. It is of the same nature as the discoloration of the 
skin following an ordinary cutaneous bruise. The yellow tint is at 
first seen only on deep pressure, but as the erythema fades the yellow- 
ness increases. The conjunctivae are not colored, and the urine appears 
normal. This yellowness is usually first noticed on the second day, 
and may continue a few days or a week. 

The term '^true icterus" can be applied only to those cases in 
which the yellow discoloration of the skin is caused by a staining by the 
bile pigments. This more often occurs in cases of prolonged or difficult 
labor, in children born asphyxiated or before term, and in generally 
feeble infants. It is very frequently seen in foundling asylums. It 
may appear as early as a few hours after birth, but usually is not marked 
until the second or third day. In very mild cases the yellow color 
may appear only on the face, chest, and back, the conjunctivae being 



DISEASES OF THE XEWLY-BORN. 19 

but faintly tinted and the urine and feces normal in appearance. In 
severer forms the urine may be high colored enough to stain the 
linen, and the jaundiced hue may extend to the arms and abdomen. 
Some infants present a yellowish discoloration of the whole body, with 
typical clay-colored stools. In most cases the jaundice has disap- 
peared by the eighth or tenth day. It may persist for several weeks. 
In rare cases, after having much diminished, it reappears with renewed 
intensity. No matter how extensive this form of jaundice may be, 
it causes very little constitutional disturbance. The liver may be 
slightly enlarged, and occasionally there are symptoms of intestinal 
indigestion. A few small doses of calomel or mercury with chalk will 
be all the medication required. 

(b) Grave Form. — This form is, fortunately, rare, and may be 
produced by several different conditions. Defects in the bile-ducts 
will first be mentioned as among the commonest causes. In some 
cases all the large bile-ducts have been absent; in others the ductus 
communis choledochus has been narrowed, obliterated, or entirely 
absent. Sometimes a fibrous cord has been found in place of the 
gall-duct. The cystic duct has been absent and the gall-bladder 
in a rudimentary condition. Accompanying an obliteration of the 
gall-ducts cirrhosis is usually found in the liver, which will be more 
or less marked, according to the length of time the infant survives. 
The liver is generally enlarged. Jaundice that is due to obstruction 
or obliteration of the biliary passages may appear a few hours after 
birth and soon acquire a marked intensity. It often, however, does 
not appear for one or two w^eeks after birth. The yellowish discolor- 
ation of the skin may vary from day to day, at times being much 
more intense than others. The conjunctivae are yellow. The fecal 
discharges lose color and have an offensive odor, while the urine stains 
the napkin a yellow or greenish-broAvn. The spleen, as w^ell as the 
liver, is usually enlarged, w^hich partially accounts for the increase 
in size of the abdomen. Umbilical hemorrhage is a grave and not 
infrequent symptom in this form of jaundice. The bleeding is not 
sudden and profuse, but begins as an oozing shortly after the separa- 
tion of the navel string. It is apt to commence at night. Death is 
always hastened by this accident, and exhaustion from loss of blood 
is added to that induced by indigestion and malassimilation. There 
may also be a species of general purpura, bleeding taking place from 
the nose, mouth, or stomach. Infants may live for several months 
with impervious or defective bile-ducts, though death usually takes 
place earlier from failure of nutrition. 

Another form of grave icterus neonatorum is observed in connec- 



20 DISEASES OF CHILDREN. 

tion with certain inflammatory changes in the liver, usually taking 
the form of an interstitial hepatitis, with which may be conjoined in- 
flammation of the biliary canals. This lesion is apt to be one of the 
results of congenital syphilis, as is likewise perihepatitis, which may 
cause a complete obliteration of the biliary passages. The latter form 
of inflammation often involves the connective tissue surrounding the 
common duct, the portal vein, and the hepatic artery on the under 
surface of the liver. These cases, however, may not always be of 
syphilitic origin. Perhaps the commonest manifestation of the grave 
form of icterus in the newly-born is seen in connection with septic 
poisoning that is generally accompanied with phlebitis. This has 
been noted under the head of sepsis. Later researches seem to prove 
that the bile itself may carry the infective agent. 

Tetanus Neonatorum. 

Although this disease is distributed through a wide geographical 
area, it is most apt to be found in filthy surroundings. Something 
beside filth, however, is necessary; there must be a specific cause. This 
consists in the tetanus bacillus, sometimes called Nicolaier's bacillus 
which produces tetanotoxin, a most virulent poison. It may exist 
in straw or dust from hay, which explains the fact that horses are 
subject to tetanus and that traumatic tetanus is often seen among 
laborers who are employed about farms and stables. 

The disease usually begins during the first ten days of life, and 
the onset is apt to be preceded by great fretfulness. Disinclination 
to nurse is soon followed by rigidity of the voluntary muscles, usually 
starting in the masseters. The rigidity increases, reaching its maxi- 
mum in from twelve to twenty-four hours. The head is thrown back, 
and there is a general flexion of the extremities. One peculiarity of 
the disease is that while the toes are flexed the great toes are adducted. 
There may be some relaxation at times, especially during sleep, but 
there are constant exacerbations, provoked by any peripheral irrita- 
tion. Respiration and circulation may be extremely embarrassed, 
and opisthotonus may be present during these exacerbations. 

The temperature is irregular, but usually high. Toward the 
end the pulse becomes rapid and feeble and death takes place from 
exhaustion. 

Treatment. — While the specific cause of the disease may gain 
entrance at any point of the body when the necessary lesion exists, 
the umbilical wound is undoubtedly the seat of infection in the great 
majority of cases of tetanus neonatorum; hence the utmost cleanliness 



DISEASES OF THE XEWLY-BORN. 21 

must be observed in cutting the cord and in dressing it. The scissors, 
the ligature, and the entire management of the navel, cord, stump, 
and the umbilical wound must be rigidly aseptic. The excess of the 
gelatinous matter should be stripped from the cord, and a dry, anti- 
septic dressing applied. Speedy mummification of the stump is the 
best safeguard against infection. Special care must be exercised in 
the umbilical dressings where the dwelling is easy of access to stable- 
yards containing horse-manure or loose earth. 

When the disease is once established it is almost invariably fatal. 
In cases of suppuration at the umbilicus, frequent cleansing with a 
solution of mercuric bichlorid of suitable strength should be employed. 
With reference to drugs, the two most valuable are potassium bromid, 
gr. iv every two to four hours, and chloral hydrate, gr. j every hour. 
The extract of calabar bean from ^V to yV grain may be given hy- 
podermatically. While these are administered the infant must be 
given nourishment frequently, and stimulants should be freety em- 
ployed. The difficulty of swallowing, however, is a source of embar- 
rassment in satisfactorily carrying out these measures. Nourishment 
may be given by the rectum or by a nasal tube. A tetanus antitoxin 
is now produced by several manufacturing chemists, but so far the 
experience reported in the serum treatment of tetanus neonatorum 
has been rather negative. 

Conjunctivitis. 

The conjunctival membrane in the newly-born is very sensitive, 
and frequently the seat of inflammation. A mild inflammation is 
often seen, unattended by swelling of the lids, the inner surface being 
reddened and covered with a slight viscous secretion. The eyes must 
be kept cleansed by frequent bathing or irrigation with a saturated 
solution of boric acid. A little vaselin may be applied to the lids to 
prevent retention of the secretion by adhesion of their edges. 

Ophthalmia Neonatorum. 

This form of purulent conjunctivitis may be due to infection by 
the gonococcus in the severer cases or by various pyogenic cocci in 
the milder ones (Koch- Weeks bacillus). If the disease manifests 
itself by the second or third day, the infection probably took place 
during birth. When there is a delay of a week or more, however, the 
virus has probably been conveyed by careless attendants, by soiled 
fingers or other infected objects. The inflammation is of an intensely 



22 DISEASES OF CHILDREN. 

virulent type, involving both the ocular and palpebral conjunctivae. 
The sac is filled with a grayish mucopurulent secretion, and there is 
intense chemosis. The subconjunctival connective tissue and skin are 
much swollen, so that the eye can only with difficulty be opened. 
There are photophobia, pain in the eye, and rise of temperature. 
Unless the symptoms quickly subside, the eye is irreparably damaged 
by ulceration and partial destruction of the cornea. The inflam- 
mation begins in one eye, but soon attacks the other unless it is 
effectively protected. 

The Prophylactic Treatment consists in employing antiseptic 
vaginal douches in the parturient woman when there is any muco- 
purulent discharge, and dropping two or three drops of a 2 per cent, 
solution of silver nitrate into each eye immediately after birth, after 
the method proposed by Crede. 

Curative Treatment.^ When the inflammation has actually begun 
the eye must be kept as free of pus as possible by constant wash- 
ings with a saturated solution of boric acid. The swelled and puffy 
lids should have applied to them every few minutes gauze com- 
presses that have been kept upon a cake of ice, and the pus must be 
removed every hour or two. Constant cleansing and cooling of the 
surface will require the services of a careful nurse night and day. A 
2 per cent, solution of nitrate of silver or of bichlorid of mercury, 
one or two grains to the pint, may be instilled between the lids every 
two or three hours, according to the severity of the case. As this 
affection so frequently results in blindness, it is well, if possible, to 
have the advice of an oculist. Protargol in 5 per cent, or argyrol 
10 per cent, solution can be recommended as a substitute for nitrate 
of silver. It has the advantage of being less painful, and is equally 
efficient. 

If the disease is limited to one side an effort should be made to 
protect the sound eye from infection by applying a compress moistened 
with an antiseptic. The pupil must be dilated with sulphate of 
atropin if the cornea is attacked. 

Mastitis. 

The mammary glands of the new-born infant often secrete a 
milk-like substance, which appears between the fourth and tenth days 
after birth. During this time there may be swelling of the glands, 
which gradually abates with the subsidence of the secretion until, 
usually by the twentieth day at the latest, both secretion and swelling 
have disappeared. In some cases, however, the glands may remain 



DISEASES OF THE NEWLY-BORX, 23 

engorged and tender, and suppuration ensue. This implies infection, 
and is exceedingly rare when proper antiseptic precautions have been 
observed during and after labor. 

Treatment. — When there is simple swelling the parts may be 
cleansed with soap and water and bathed with a weak antiseptic 
solution, either of carbolic acid or bichlorid of mercury. Gentle 
support with absorbent cotton and a bandage will also be indicated. 
If, in spite of this, suppuration occurs, there will be rise of temperature 
and the local signs of abscess. Then early incision, under proper 
antiseptic precautions, constitutes the treatment. 

Spontaneous Hemorrhages in the Newly-born. 

In addition to the accidental hemorrhages during the process of 
delivery caused by pressure effects, we may occasionally have spon- 
taneous hemorrhages during the first week of life that are independent 
of birth. These hemorrhages may occur in connection with various 
forms of sepsis, with congenital syphilis or from unknown causes. 
A general predisposing cause doubtless exists in the great alteration 
in the circulation induced by the transition from fetal to extrauterine 
life, from the rapid changes taking place in the blood at this time, and 
the fragile state of the Avails of the blood-vessels. The blood may 
ooze from the mucous membrane of the nose, mouth, gastrointestinal 
tract, umbilicus, or vagina. The skin may also be affected, especially 
at the occiput, along the back and wherever pressure is apt to be 
exerted. There may likewise be small extravasations in the various 
viscera, but these are not usually recognized during life. The hemor- 
rhage takes the form of slow, continuous oozing and is not apt to last 
more than one or two days. While the actual loss of blood may not 
be great, a large number of the cases die from exhaustion, as losses of 
blood are not well tolerated at this time. The bleeding is apt to 
start from the intestinal tract, called melena neonatorum, when the 
infant may be restless or somnolent, with bloody stools, and occasion- 
ally vomit hemorrhagic masses. The umbilicus may begin to show 
oozing a few days later and hematuria is sometimes noted. Where the 
hemorrhage is limited to the nose, congenital syphilis is probably 
the cause. While the etiology of some of these cases is obscure, the 
condition is different from hemophilia, and the hemorrhages usually 
stop spontaneously in a few days. 

The prognosis is bad, the infants succumbing to exhaustion. 
Among 709 cases collected by Townsend 79 per cent. died. The 
treatment consists in trying to keep up the strength by careful feeding 



I 

I 24 DISEASES OF CHILDREN. 

and stimulation and by employing adrenalin in connection with the 
bleeding surfaces when they can be reached. 



Various diseases and affections that are often seen in the newly- 
born, but not confined to this period, wdll be discussed in their appro- 
priate sections. Among these may be noted tuberculous infection, 
congenital syphilis, thrush or sprue, colic and indigestion, edema, and 
pemphigus. 



SECTION 11. 
HYGIENE OF INFANCY. 



CHAPTER IV. 
HYGIENE OF INFANCY^ 

After birth a careful inspection of the infant should be made to 
discover any defects that may be present. The body should then be 
thoroughly oiled, and, if the infant is cold or gives evidence of poor 
vitality, it may be wrapped in cotton batting and put in a warm place 
for rest. Vigorous children may be bathed in water at 100° F. shortly 
after the oiling and then dressed. The first bath must always be given 
expeditiously in a warm room. A dry dressing is best for the cord, 
which, after a thorough powdering, may be wrapped in sterile gauze. 
A daily sponging of the body with castile soap and warm water will take 
the place of the bath until after the cord separates. A pad of sterile 
gauze may be applied over the umbilicus for several weeks and kept in 
position by the abdominal binder. 

The eyes can be cleansed with a saturated solution of boric acid 
or a 2 per cent, solution of nitrate of silver where a purulent vaginal 
discharge has existed in the mother. The mouth may be gently wiped 
out with boiled water and a teaspoonful of tepid water given to swallow. 

Clothing. 

The clothing consists of an abdominal binder of flannel, which, 
in a few months may be changed in vigorous infants to a knitted band 
with shoulder straps. The binder should not press so tightly as to re- 
tard the free expansion of the lungs in breathing. Next will come a 
shirt with a little extension below to which the diaper may be attached 
by pinning and then a flannel petticoat. Finally a dress of some light 
material will complete the raiment. Care must be taken to have the 
clothing neither too tight nor too loose. In the former case, the 
free movements of the chest, abdomen and legs are interfered with, 
while in the latter instance the clothing creases or works up and down 
in a manner to cause much discomfort. Long, warm stockings, with 
knitted bootees will keep the lower extremities protected in cold 
weather, and in the warm season, short, thin socks may be substituted. 
In early infancy the clothing is made long enough to well cover the 

25 



26 DISEASES OF CHILDREN. 

feet, but it is not necessary to have dresses and petticoats unduly 
long so as to drag on the feet. The Gertrude patterns are excellently 
adapted to the dressing of infants as the several pieces may be put on 
at one time, obviating unnecessary handling. Diapers may be made of 
linen, cotton, stockinet, or canton flannel, according to the season, care 
being taken to have them snugly applied and warm. Watchfulness of 
the nurse is required to have them quickly changed after being soiled. 

The Nursery. 

This should be a large well-ventilated room with a sunny ex- 
posure. The temperature should be kept constant — from 68° to 70° F. 
during the day and at night from 65° to 55° F., according to the age and 
vitality of the infant. An intake of fresh air without a draft may be 
accomplished by fitting a board under the lower window sash. If 
possible heat the room with an open fire on account of the ventilation. 
When furnace heat is employed, a thorough airing twice a day by 
widely opened windows is desirable. 

Bathing. 

After the cord has separated, a daily bath may be given. For the 
first six months the temperature of the water may vary from 98° 
to 100° F. ; from six to twelve months, 95° to 98° F., and after one 
year it may be as low as 90° F. A good grade of soap — French or 
castile — may be used, and the lather removed by plunging the infant 
in the water. The skin must be thoroughly but gently dried without 
undue friction, and the folds of the skin and genitals powdered. The 
prepuce is to be retracted to prevent the collection of smegma. Finally, 
the eyes and mouth may be cleansed with a warm solution of boric 
acid. When the skin is thin and irritable, or the seat of eczema, bran 
baths ma}^ do well. In severe cases of eczema, the skin may be 
cleansed by rubbing with sweet oil or vaselin. 

Exercise and Fresh Air. 

When awake, the infant should not be allowed to lie continuously 
in its crib, as the gentle exercise of being held or carried about is bene- 
ficial. They should always be taken up for feeding. The arms and legs 
must not be so constricted by the clothing as to prevent easy move- 
ments and, when undressed, a little time for free play of all the muscles 
is beneficial. In warm weather, the infant can be taken out of doors 
as early as the second or third week, in spring and fall at from four to 
six weeks, but if born in winter, unless the Aveather is mild, it may be 
wiser to give it its airings in the house until spring. In cold weather 



HYGIEXE OF INFANCY. 27 

it is best to give the outing between 10 a. m. and 3 p. m. when the sun 
is out, but the face and eyes must be carefully protected from the 
sun's rays. Never expose an infant to wind. When the temperature 
of the air is below 30° F. it is better to stay at home, except in the 
case of very strong infants. The baby can sleep out of doors, but 
care must always be taken to see that it is sufficiently warm during 
the winter months. In very cold weather or when there is melting 
snow, the infant may get fresh air by being warmly clothed, put in a 
room with a sunny exposure and have the window opened. The room 
must then be otherwise closed to prevent a draft. It is possible in 
this way to avoid the dust of the streets in windy weather. It is like- 
wise safer to take the fresh air in this manner in damp, foggy weather 
when there is no sun. 

General Habits. 

It is well to start early in training the infant to habits of regularity. 
Sleep is encouraged by putting the infant in its crib with a firm mat- 
tress, but with the head low, resting on a folded pad, darkening the 
room, and attending to proper ventilation. Rocking as a preliminary 
or accompaniment of sleep is undesirable. If feeding-time comes during 
sleep the infant can be awakened for this purpose, as he will usually 
sleep again after nursing or learn to wake at the proper time. The 
nurse need not hasten to take a baby up the moment it arouses and 
cries, as it will frequently go to sleep again after a few moments of rest- 
lessness. During wakeful hours, and especially late in the day, the 
infant must not be excited by too much playing and attention, as this 
induces delayed and disturbed sleep. The very young infant should 
sleep most of the time, from eighteen to twenty-two hours daily during 
the first months. At six months the baby usually sleeps two-thirds 
of the time, and at one year over half the time. 

Much can usually be accomplished by an early training of the 
bowels. As early as the third month the infant can be placed at regular 
times on a small commode for this purpose, taking care to support the 
baby in the proper position. At a year, efforts may be made to train 
the bladder by encouraging the young infant to indicate his desire 
for urination. After many trials progress will be made in this direction. 

The greatest regularity in feeding must be entailed from the first, 
but the necessary details will be considered in the chapter on feeding. 
Water must always be regularly given, even the newly-born getting a 
few teaspoonfuls daily. 

The young infant must always be kept quiet, as the rapidly grow- 
ing nervous system suffers from romping and too much attention. 
This must especially be enforced late in the day. 



CHAPTER V, 

WEIGHT AND DEVELOPMENT. 

It is important to have a record of the birth weight in every case> 
The male infant usually weighs a little more than the female. In a 
series of 200 cases examined by the writer the males weighed from 6 
to 8 pounds and the females from 5^ to 7 pounds. As many of these 
were born in institutions the averages of hght weight were fairly large. 
Seven pounds may be considered a good average birth weight. As far 
as initial weight may be considered a gauge of vitality, 6^ pounds will 




Fig. 7. — Platform scale for weighing the baby. 



show a good vitality, 5^ pounds a rather poor vitality and from 4 to 5 
pounds a very poor vitality at the start. During the first few days 
there is generally a loss of from four to six ounces after which there 
should be a steady gain. It must be remembered, however, that babies 
are apt to gain irregularly at short intervals. One day the infant may 
show a gain of an ounce and the next day a quarter of that amount 
while doing perfectly well. Again, the weight may remain stationary 

28 



WEIGHT AND DEVELOPMENT. 



29 



for a day or so, and then jump up two ounces in twenty-four hours. 
According to Rotch, there should be an average daily gain from birth 
to five months of 20 to 30 gm. (two-thirds of an ounce to an ounce), 
and from five to twelve months of 10 to 20 gm. (one-third to two-thirds 
of an ounce). This would mean an average weekly gain during the 
first five months of about four and a half ounces to seven ounces, and 
from five to twelve months of from about two and a half to four and a 
half ounces. 

The infant should double its birth weight at five or six months, 
and treble it at from twelve to fifteen months. The weighing should 
be done by the same person either on grocer's scales or those specially 




Fig. 8. — Normal infant. Typical attitude. 



constructed for infants. Daily weighings are deceptive and undesir- 
able. During the first six months, once a week is sufficient, and, in 
the second six months, once in two weeks is often enough in cases that 
are doing well. Careful records should be kept, and charting is con- 
venient for reference. 

The length of the new-born baby is shghtly greater in the male 
than in the female. In the series already noted that was examined by 
the writer, the males averaged 50 cm. (19.6 inches) and the females 
48.6 cm. (19.1 inches). In private practice, with healthy parents, 
the length will average about 20 inches. Growth in length is most 
rapid during the first month, a little less so during the second, the 
rapidity decreasing with each month. The following figures are 
taken from Rotch: The average increase for the first month is about 
4.5 cm. (If inches); for the second month about 3.0 cm. (H inches); 
for the third to the fifteenth month about 1 to 1.5 cm. {h to J inch); 



30 DISEASES OF CHILDREN. 

for the first year about 20 cm. (8 inches); for the second year about 
9 cm. (3^ inches); for the third year about 7.4 cm. (3 inches). 

Just after birth the trunk, arms, legs, and head have pecuhar con- 
formations. The body is of an elliptical shape, with the widest part 
at about the center over the liver, in the region of the lower ribs. The 
two ends of the ellipse, represented by the thorax and pelvis, are small 
and not well developed. The arms are stronger and better developed 
than the legs. During intrauterine life the baby is placed in a sort 
of squatting position with the legs drawn up and curled inward. This 
explains why the legs of the young infant are not straight, but show a 
decided bowing of the tibia and fibula. The soles of the feet also 
tend to point inward. The head is larger than the chest' at this time, 
with a very short neck, and the baby assumes a position of general 
flexion. 

While infants at birth may vary in size, each individual should 
develop in proper proportion, the various parts of the body bearing a 
symmetrical relationship to one another. The circumference of the 
head is greater than the circumference of the chest at birth, and re- 
mains so up to the middle of the first year, when they begin to approxi- 
mate in size; at the end of the first year the chest expands to a greater 
circumference than the head. If later than this time the circumfer- 
ence of the head remains greater than that of the chest, it is an indica- 
tion of rickets or hydrocephalus. The following diagrams done in 
scale from 200 measurements will show to the eye the average relation- 
ships found at various ages. 

The Head. — The sutures of the skull should be ossified by the 
sixth month; the posterior fontanel closes at the end of the second 
month and the anterior fontanel from the sixteenth to the eighteenth 
months. Any deformities of the head due to prolonged pressure in 
difficult labors are usually overcome during the first few weeks. After 
birth and with increase in age, there is noted a gradual and steady 
enlargement of the great circumference of the skull, and, from this, 
of its estimated volume. Although no intellectual growth can be said 
to take place under two years, there should be an active evolution of 
the front of the brain, with increase of the perceptions. The first rapid 
growth of the brain after birth is more in bulk than in the size and com- 
plexity of the convolutions. Hence in early infancy the higher centers 
have but a slight development and function. With proper evolution, 
the convolutions grow and become arranged in functional groups, 
which groups, by their growth, alter and modify the shape of the in- 
fantile skull. If the skull is small or improperly shaped in any part, 
the brain in such area is imperfectly developing. A certain amount 



WEIGHT AND DEVELOPMENT. 



31 



of asymmetry is, however, found in all skulls as in other members 
of the body and, unless very marked, has no great significance. 

The principle of biology that the development of the individual 
reproduces on a small scale the development of the race, is well shown 
in the infant's brain. The higher centers and the association fibers 
are developed late in the child; they are likewise the latest acquirements 




LENGTH 




20.7 



WEIGHT 
7LBS.12 0Z. 



LENGTH 



NEWBORN 




26.2 



LENGTH 



WEIGHT 
15.4 LBS. 



6 MOS. 



27.7 



WEIGHT 
18 LBS. 9 OZ. 



12 MOS. 

Fig. 9a. — Diagrammatic table of relative measurements. 

of the race. The lower and more fundamental animal traits are trans- 
mitted by inheritance in greater degree than the higher ones. 

The skull changes considerably in its proportions during the first 
years of life, and then more slowly up to the end of the seventh year, 
when it has very nearly attained its full size. At birth, the circum- 
ference of the head averages from thirteen to fourteen inches, at the 
end of the second year about eighteen inches, at the seventh year about 
twenty and a half inches, and at the completion of growth twenty- 
two or more inches. 



32 



DISEASES OF CHILDREN. 



Just after birth the brain and nerve centers act only automatically, 
or by reflex action. Touch and taste are present at birth, but the 
baby is deaf for the first few days and it will not follow an object with 
its eyes until the third week. The eyes should never be exposed to 
bright lights. By the third month the baby reaches out its arms for 




LENGTH 




29.8 



LENGTH 



WEIGHT 
22 LBS. 2 OZ. 



32.0 



18 MOS. 



WEIGHT 
24 LBS. 



24 MOS. 



Fig. 96. — Diagrammatic table of relative measurements. 

objects and may recognize individuals. The rudiments of memory are 
now developed, and by the fourth or fifth month a few people may be 
remembered and recognized. It is not until the third year, however, 
that memory develops very rapidly. Efforts at speaking usually 
begin at the end of the first year when single words may be uttered, 
and at the close of the second year short sentences may be tried. 



WEIGHT AND DEVELOPMENT. 33 

The Spine. — The spinal column is curved but very flexible. In 
early infancy the so-called normal curves are not developed above the 
sacrum, but there is one long curve in the shape of a convexity above 
the latter bone. With the strengthening of the spinal muscles, and 
when the child begins to stand and walk, the normal cervical, dorsal, 
and lumbar curves begin to develop. As the child grows older the 
spine becomes less flexible and more rigid with increased power in the 
spinal muscles. There is, however, much more flexibility all through 
childhood than in adult life; when the spine loses its mobility, and 
especially when it is stiff or painful on motion, caries may be suspected. 
At birth the spinal cord extends as far as the third lumbar verte- 
bra, while in the adult the lowest portion of the cord is opposite the 
second lumbar vertebra. The spinous process of the fourth lum- 
bar vertebra is about on a level with a line drawn between the highest 
points of the crests of the ilia. 

Glands and Viscera. — The lacrimal glands are usually not 
developed sufficiently to shed tears for three or four months. The di- 
astase-forming organs — the salivary glands and pancreas — act very 
feebly during the first two or three months. The sebaceous glands are 
early active, as seen just after birth in the vernix caseosa and later in 
dry seborrhea. 

The thymus is large at birth, increasing slightly in size to the end 
of the second year and then remaining uniform in size until puberty, 
when it undergoes atrophy. 

The stomach is somewhat like a vertical sac at birth, but gradually 
develops in a horizontal direction; the intestines are relatively long 
with a sigmoid flexure that is accentuated and with sharper curves 
than in older subjects. The intestinal muscles are weak, which ex- 
plains the ease with which the bowel becomes distended with gas. 
The appendix is very long and narrow in lumen. The liver is large, 
reaching a little below the free margin of the ribs. 

The bladder is well developed and usually extends up into the ab- 
dominal cavity on account of the smallness of the pelvis. In female 
infants the bladder may be mistaken for the uterus at autopsy. The 
testicles should be located in the scrotum at birth, but they may re- 
main undescended in the abdomen or caught in the inguinal canal. 

The Muscles. — In the musculature, the greatest relative strength 
is shown in the hands and arms for a time after birth. At about three 
months the muscles of the neck have developed sufficiently to allow 
the infant to hold up its head in an uncertain way. At the seventh or 
eighth month the muscles of the back have become strengthened so 
that the baby can sit up, and shortly after this it may be allowed to 
3 



34 DISEASES OF CHILDREN. 

creep. Free play should be given to the muscles of the arms and legs 
from the first, as muscular and bony development are thereby encour- 
aged. The bones of the legs thus grow and straighten out, but this 
will be checked if the infant is made to sustain the weight of the body 
too soon. The average baby should not be encouraged to stand before 
the twelfth month. Efforts to walk may be started from then on to 
the fifteenth or sixteenth months. When walking has been established, 
the legs should be straight. 

Dentition. — The process of dentition begins early in intrauterine 
life, and the cutting of the temporary or milk-teeth should be completed 
at the end of infancy. At birth, although nothing but smooth gums 
are to be seen, the alveolar processes enclose the twenty temporary teeth 
in embryo. When beginning to come through the gums, they usually 
appear in groups. Even in healthy infants there is often some varia- 
tion in the order and time of the eruption of these first teeth, but the 
earliest to be cut are usually one or both of the middle lower incisors 
at the sixth or seventh month. The rest are gradually evolved, 
generally in the following order: upper central incisors, upper lateral 
incisors, lower lateral incisors, four anterior molars, four canines, and 
finally the four posterior molars. The following table may serve 
as a general guide: 

Middle lower incisors, sixth to eighth month. 

Upper central incisors, eighth to twelfth month. 

Upper lateral incisors, tenth to twelfth month. 

Lower lateral incisors, twelfth to fifteenth month. 

Four anterior molars, fourteenth to sixteenth month. 

Four canines, eighteenth to twentieth month. 

Four posterior molars, twentieth to thirtieth month. 

As in other functions there is more or less variation within the 
limits of health; such irregularity as the lateral incisors being cut be- 
fore the central incisors may occasionally be seen. In rare cases in- 
fants are born with teeth, but these are poorly developed and lost 
early. Certain unusual cases of rickets, contrary to the common rule, 
may show very early dentition, perhaps beginning as early as the 
third month, but such teeth are poor. 

Delayed Dentition. — Much delay in teething is an evidence of 
faulty nutrition or constitutional disease, principally rickets. If an 
infant has cut no teeth by the end of the first year there will nearly 
always be marked evidences of rickets present. The latter disease is 
the commonest cause of delayed dentition. The teeth of rickety chil- 
dren are often poorly developed and prone to decay, even the second 
dentition may be similarly affected by this disease. Cretinism is 



WEIGHT AND DEVELOPMENT. 35 

another cause of very slow dentition. In general, bottle-fed babies 
are slower in cutting teeth than those brought up on the breast. 

Disturbances of Dentition. — Many bodily disturbances for- 
merly attributed to teething are now known to have other causes that 
have been revealed by more accurate diagnosis and pathology. This 
is a period of rapid growth and instability, especially of the digestive 
and nervous systems. Many troubles at this time are due more to 
faulty care and feeding than to any normal physiological activity and 
growth. Still a certain number of infants do show disturbances at this 
time that are apparently due to the eruption of teeth, as careful ex- 
amination fails to show other cause. There may be evidences of ner- 
vous discomfort shown by constant restlessness and fretfulness, dis- 
inclination to take food, and various grades of indigestion. There is 
drooling with swollen gums, and the infant keeps putting its hands into 
its mouth. As light, irregular temperature may also develop that will 
be aggravated by indigestion if food is forced in too great amount or 
strength. In a few cases the infant seems much sicker, with high 
fever and severe nervous symptoms, such as semi-stupor or convulsions. 
Rickety babies are prone to the latter. Most cases, however, show the 
disturbances of dentition rather by an aggravation of any existing 
trouble that otherwise might hardly be noticeable. 

The treatment consists in careful regulation of the diet, which 
will usually take the form of temporarily weakening the food, and in 
giving a sedative, such as sodium bromide. Incising the gums is not 
advised. Any diarrhea at this time must receive prompt and careful 
attention. 

Care of Temporary Teeth.— The teeth must be cleansed twice 
daily by gently rubbing up and down with a very soft, wet tooth-brush. 
The health and preservation of the temporary teeth are necessary to 
favor a good set of permanent teeth. Any pyogenic germs allowed to 
lodge in the roots may injure the permanent teeth; milk-teeth must 
accordingly be filled if carious and preserved as long as possible. They 
also tend to preserve the alveolar shape. 

Permanent Teeth. — There are thirty-two in the complete set. 
The first molars are usually the earliest teeth to appear in the second 
dentition, at the sixth or seventh year. Then the central and lateral 
incisors, from the seventh to the ninth year; the bicuspids from the 
ninth to the tenth year; the canines from the twelfth to the fourteenth 
year; the second molars from the twelfth to the sixteenth year; and the 
third molars, or wisdom teeth, from the seventeenth to the twenty-first 
year, or even later. 

The proper development of the permanent teeth may be interfered 



36 DISEASES OF CHILDREN. 

with by malnutrition or repeated attacks of stomatitis which may cause 
a poor formation of dentine and enamel. The ends of the incisors and 
molars may show constrictions and erosions. Carious teeth frequently 
cause earache, neuralgia, adenitis in the neck, and poor nutrition from 
chronic indigestion due to imperfect mastication. 

Hutchinson's Teeth. — Congenital syphilis will sometimes induce 
a change in the upper central incisors of the permanent teeth only, 
known by the name of their discoverer. They are small and peg- 
shaped, with scooped-out grinding edges, usually deflected inward; 
occasionally they are deflected outward. 

Growth during Childhood. 

The increase in weight and height depends upon race and climate 
as well as on the size and physique of the parents. It is thus evident 
that no absolute rules can be given for comparison that will apply to 
all children. We have already given data as regards infancy, when 
growth is steady and rapid. After the period of infancy, growth is not 
relatively so rapid and takes place more in cycles. It depends very 
largely upon good heredity, and a healthy well-nourished state during 
the first years of life. Biological researches have shown that favorable 
embryonic conditions and good nutrition during the earliest years have 
the greatest influence in determining the full height and development 
of the individual. If a child is fortunate in its birth and well nourished 
up to its fifth or sixth year, there will probably be a normal growth 
thereafter, as, even if there are poor conditions later on, nature will 
probably be able to compensate for them. Each individual has a 
certain normal size to attain which will usually be reached if the first 
years have been favorable. It is difficult to make up, however, for 
early unfavorable conditions. 

The two principal periods of acceleration of growth occur during 
the second dentition and at the period of adolescence. This roughly 
corresponds, first, with the period from six to nine years in boys and 
girls, and second, from eleven to thirteen in girls and from fourteen 
to sixteen in boys. This cycle of increase in height should precede 
and be shortly followed by an increase in weight. There also tends to 
be some variation in growth at different seasons. In a series of cases 
quoted by Tanner, the period of most rapid increase in height among 
seventy boys, from seven to fifteen years of age, was found to be from 
April to August, and the least from August to December, while the 
greatest increase in weight occurred from August to December, and 
the least from April to August. 



WEIGHT AND DEVELOPMENT, 



37 



>; 


























a 
























Q 


























6 


























^ 


























>. 
























rt 


























Q 


























d 


























S 


























>. 






















03 
























P 
























d 
























S 
























>. 






















d 


1 






















Q 
























6 
























. S 
























>. 






















ri 
























Q 


























d 


























^ 


























>. 
























c3 


























Q 


























d 


























S 


























>. 
























CIS 


























Q 


























d 


























S 


























>. 
























CvJ 


























« 


























d 


























S 


1 : 




















>. 
























oj 


























Q 


























d 


























§ 




























O 
























i 


o 










a 








s 
















c 


S 






o 


S 


















-+-r 


.=f 


^ 






; 












o 


O 


!5 


13 
















o 


o 


o 


qT 


6" 


o" 


qT 


oT 












o 


o 


o 


o 


o 


a 


o 


.2 












c: 


£3 


C 


C 


C 


C! 


a 


'-I3 












© 


o 


o 


o 


c 


o 


o 




1 










f^ 


%^ 


fc. 


{^ 


tH 


^ 


t. 


>— 1 












o 


c 


o 


o 


o 


o 


o 


03 


























s 








-1-3 


-4^ 

^b£ 


's 


's 


g 


'b 


a 


^ 


^ 




o 




T£ 


3 


13 


3 


13 


3 


13 


3 


O 






o 




o 


o 


o 


o 


o 


O 


o 


c 


, 


c 


< 






O 




1 G 




5 


Q 


< 



38 



DISEASES OF CHILDREN. 



Whenever there is a rapid increase in height, the child is apt to grow 
thin and anemic, as the making of bone particularly uses up the 
red blood-corpuscles. The children then become nervous and irri- 
table, requiring extra care at home and school. 



15Kyrs. 



12Kyrs. 



6Myrs. 



43.9 
inches 



45.2 lbs. 



9K 


yi-s. 


50.0 
inches 


• 


59.6 IDs, 



55.4 
inches 



62.9 
inches 



76.9 libs. 



107.4 lbs. 



Fig. 9c. — Diagrammatic table of relative measurements. 



In order to present a guide of average growth, the following tables 
have been combined and compiled from the studies of Boas on the 



rate of growth in height and 
children: 



Burke on the weight of American 



Table of height and weight of American boys. 



Years 


Average height (Boas) 


Average weight (Burke) 


61 


43.9 inches 


45.2 pounds 


7i 


46.0 inches 


49.5 pounds 


8i 


48 . 8 inches 


54.5 pounds 


9i 


50.0 inches 


59.6 pounds 


121 


55.4 inches 


76 . 9 pounds 


151 


62.9 inches 


107.4 pounds 


181 


67.4 inches 





I 



WEIGHT AND DEVELOPMEXT. 39 

Table of height and weight of American girls. 

Years Average height (Boas) Average weight (Burke) 

6^ 43 . 3 inches 43 . 4 pounds 

7^ 45.7 inches 47.7 pounds 

• 8 J 47.7 inches 52.5 pounds 

9^ 49.7 inches 57.4 pounds 

12^ 56.1 inches 78.7 pounds 

15^ 61.6 inches 106.7 pounds 

18} 114.9 pounds 

Mental and Moral Growth. — The mental development of the 
child must be carefully watched from the beginning. Just as the 
human embryonal life represents various upward stages of animal de- 
velopment, so the child's mind reproduces in miniature the earlier stages 
of the growth of the race. It is early necessary to recognize the vari- 
ous tendencies that manifest themselves in a growing child, so that they 
may be guided aright. It must be remembered that the child exhibits 
the elemental human forces and instincts. Just as" the emotions are 
developed in the race before the reason, so it is with children, who can 
be moved by their sympathies long before they can be influenced by 
their intellect. Love is a surer guide for them than reason. This is 
the secret of success of many mothers and of some teachers. The 
most lasting impressions of childhood come through the feelings. 

At the end of infancy, and during early childhood, the imitative 
faculties are especially dominant. The acts of older children, of adults, 
and even of animals are faithfully copied without much idea of their 
significance. Up to the age of seven years much of the training and 
education of the child must come from imitation. Before this age 
nearly all the playing of children is imitative, shown by the dehght 
in toys representing articles in real life, but after this, especially in 
boys, the games take on a more competitive form involving muscular 
exercise. 

There exists in some children a touch of barbarism that is merely 
an evidence of underdevelopment. Apparent cruelty, shown in a 
callousness to suffering, is sometimes seen, but this is rather due to a 
lack of experience as to the meaning of pain than to defective moral 
sensibilities. The conduct of the child is largety influenced by the tone 
and temper of those around him, in the intellectual as well as in the 
moral sphere. A cultivated home will do more for the proper devel- 
opment of the child than the formal education of the finest schools. 

Adolescence. — The beginning of this period is a most interesting 
and critical time for the child. Up to this time, as already noted, the 



40 DISEASES OF CHILDREN. 

child has hved the race hfe, but he now begins to develop individual 
characteristics, and family traits come out more strongly. There is a 
rapid growth of all parts of the body, especially marked in the reproduc- 
tive organs and the heart and lungs, with increase in blood-pressure and 
in general glandular activity. The appearance of hair on the pubes 
is considered characteristic of the period. The peculiarities of sex 
now begin to manifest themselves; boys and girls cease to mingle in 
such an indiscriminate way as in earlier childhood. Up to twelve 
years there need not be much differentiation of the sexes, but after 
this they must be separately considered. Vague aspirations and a 
general restlessness show the stirring of new life in the child's mind. 
Both the emotional nature and the imagination become very active. 
If any trait is entirely absent at this time it is not apt to be seen later 
in life. 

As growth and development are so rapid during adolescence, 
nothing must be allowed to conflict with the physical nature at this 
time. Overstrain in school must be guarded against. It has been 
proven from examinations of many school children that, as a rule, 
the heaviest and tallest, or those with the best physique, stand highest 
in their classes. Hence if a child is poorly nourished or undeveloped, 
the best thing, even for his intellectual growth, is to focus attention on 
his body for a time and let his mind be temporarily neglected. Appar- 
ent stupidity or bad mentality in school children is often the result 
of physical causes that may and should be removed. Deafness, defect- 
ive eyesight, enlarged tonsils and adenoids, and poor nutrition from 
lack of proper food may be especially mentioned in this connection. 



SECTION III. 
THE EXAMINATION OF THE SICK CHILD. 



CHAPTER VI. 
THE EXAMINATION OF THE SICK CHILD. 

If the physician unaccustomed to the care of children will first 
learn what to expect to find in the normal child, he will better appre- 
ciate the variations in disease. He must first of all learn that a proper 
examination will take time, and that a hurried examination often leads 
to grievous errors. Having once made up his mind to be systematic, 
thorough, and painstaking, the bugbear of pediatric practice will begin 
to disappear, and diagnoses will be made where formerly there was dis- 
appointment and confusion. The younger the infant or child, the greater 
are the peculiarities from the adult type in its relation to disease. 

History. — If possible obtain the anamnesis outside of the nursery. 
It should preferably be obtained from the mother or attendant who 
has been in closest attendance upon the child. First — elicit a natural 
story as to the change from the healthy child to the sick one. If digres- 
sions are made they can be guided back to the proper channels. This 
will give a clue to the nature of the illness, and the further questions 
will be modified considerably thereb}^ For example, if the disease 
be one of malnutrition, most careful details of previous feeding from 
the time of birth will be pertinent, and the dietary life traced to the 
present time. Heredity and environment are inquired into, and 
previous illnesses recorded on properly prepared history blanks. The 
accompanying history card, as suggested by Dr. R. S. Haynes, is one 
that is convenient to carry, and tends to making recording systematic 
and of value without much waste of time and energy in writing. 

Inspection. — The child asleep. Trained observation is the most 
valued asset of the podiatrist. If possible, examine the child while it 
is asleep. Sit by its crib and watch it. Its general posture, if quiet 
or restless is to be noted. The breathing as to its character must like- 
wise be observed, and the number of respirations per minute counted. 

Respirations. 
Newborn, 35 to 45 First to second year, 20 to 25 

First to the second month, 24 to 36 Second to sixth year, 20 to 23 
Second to the sixth month, 20 to 32 Sixth to twelfth year, 18 to 20 

41 



42 



DISEASES OF CHILDREN. 



< 



CO 

If 



!m 









(^■^^ 



+3 d 



13 
O 

"I 









03 

a; 



m 



B< 



wg 









m 





(u 


OJ 


-4-3 


o X 


6 


H 


43 


03 CO 


d 






o 


"o 


a 


w 






^ 




-4J 






o 




03 







w 



Q 



o 






BZ 

w 



13 }:; o <l^-^ 02 

o O 






O 



cu 



• 43 ^'o O 



. O tB •:2 ^^ r^ ^ ^ 








d 




PQ 


Ul 


^ 




- ^ 




02 




. -1-3 




gS 




^H 




r^-- 


^ 


H.=^ 


c 


■+3 .'3 


;:3 


O lA <^ <o 



O u 



So 



c3 



M ^j O 

o; 03 J:.- 



£ Si 

u 



a 




o 




HH 


■73 


H 


03 


<s: 


w ^ 


s 


6o^ 


t-H 




^ 


< 




X 




w 





03 



■ :3 o ^ o 



Sc/i|z;gH P4 



e^ o 






Q 

PQ 

<: 

o 
O 

S 

.d 



T3 
C 
O 

o 

hJO 0) 



03 fl 



O 



«3 ^ 

(U 03 



d; 5 vi S o c^ CtS CI 
W § H H^ H W i-KC O 






^ff 




"Qh 








■p. 




H 


en 




-sa 




s^ 


•-;2o 


P^W 


S 


-, "cS 


a> 


0).^ 


V4 


C o 




.3 (u 


X 


Wh o. 


WHtSw 



THE EX.\MIXATION OF THE SICK CHILD. 43 

The respirations may be counted by the hand on the abdomen or 
by observation alone. 

If the neck and chest can be exposed without waking the child, 
additional information is gained by observing the effect of the respira- 
tions on the supraclavicular and suprasternal spaces. 

Mouth breathing is easily detected in sleep, and the half-closed 
eyelids are indications of the weakened state. The pulse may now be 
obtained without awakening the child with a little care, and is a more 
reliable guide than when influenced by fright. 

If there is gastrointestinal disturbance inspect the last soiled 
napkin. 

The Child Awake. — Enter the room without apparently taking 
much notice of the patient; a cheery word of greeting and an interest 
in his favorite toy will often be sufficient to disarm suspicion and win 
a friend. Now have the patient entirely undressed. 

In the case of an infant it is best examined on a table in a good 
white light; if a child, allow it to sit up. (If you wish a child to cry at 
once make it lie down.) If the infant is crying, much valuable informa- 
tion is obtained if this is properly interpreted. (See section on signs 
of illness, p. 73.) 

First begin your inspection as to general development, muscula- 
ture, emaciation, and the condition of the skin, as these factors will 
influence or modify local changes seen elsewhere. Beginning at the 
head, note any abnormalities in detail, i.e., as to its size, shape, hair, 
eyes, eyelids, pupils, nose, mouth, gums, teeth, etc. 

The significance of abnormal conditions as seen here are given 
in the suggestive diagnostic key, which see (p. 100). Note the contour 
of the neck, the presence of enlarged lymph-glands, the spaces above 
the clavicles, the chest itself, if well formed, or if showing any bony 
changes; whether there is a visible apex beat or a thrill over the pre- 
cordium; the movements of the upper extremity, if natural, or if 
there is any paralysis; the finger-tips may give valuable information 
as to circulatory or pulmonary involvement; the abdomen if distended 
or sunken; the external genitals for abnormal formation or dis- 
charge. The lower extremities are compared to the upper for devel- 
opment, bony changes and mobihty. The infant may now be turned 
over and the back of the head, spine, and rectum examined. 

The temperature should always be taken in the rectum. The 
best plan with an infant is to have it lying face down across the lap 
of the nurse. An older child is least annoyed by the procedure if the 
thermometer is inserted while the patient is lying on the side. It 
should be pushed past the sphincter and remain in the rectum for 



44 



DISEASES OF CHILDREN. 



three minutes. The range in the normal infant varies from 98.8° to 
100.2° F. Premature infants quite constantly have a slightly subnor- 
mal temperature. Daily variation of several tenths of a degree are 
noted. The average temperature in early infancy is 99° F. 

Palpation. — This is more readily and satisfactorily accomplished 
if both hands are used. 

Beginning at the head, the right hand palpates the right side of 
the body and the left hand simultaneously palpates the left side. The 
contour of the head and the fontanels are thus easily ascertained. 
Craniotabes, if present, will not escape attention. Any glands in the 




Fig. 10. — Method of palpating liver and spleen. 



occipital region are palpated and noted if enlarged. The lower eyelids 
are pulled down by the fingers and the mucous membrane examined. 
Slight pressure on the chin will afford an inspection of the lips, teeth, 
and tongue; the examination of the throat being left for the final 
procedure (p. 368). The hands are now passed over the neck to 
find any abnormalities in the anterior group of glands. Next the 
shoulder-joints and the axillae are explored; at the same time the 
musculature will be estimated to aid in establishing the degree of 
physical development. The epitrochlear glands should not be for- 
gotten in the examination. The hands of the patient are palpated for 
temperature, irregularities, or clubbing. The pulse is best counted 
when the child is asleep. The carotid or temporal pulse may be used 
if the wrist is not exposed. 



THE EXAxMIXATION OF THE SICK CHILD, 



45 



In extremely weak infants the count is taken of the heart beats at 
the apex by using a stethoscope. 
The pulse varies from: 

120 to 140-in the new-born, 
f 110 in the first year, 
and averages | 100 in the second year. 

[ 90 in the fifth to the eighth year. 
If the child is irritated, crying, or in pain, the pulse rate will be 
accelerated, and a note should be made of this circumstance. The 
force and character of the pulse are of as much importance as its 
frequency. 





Fig. 11. — Method of eUciting Kernig's sign. 



The apex beat on the chest wall may be located, or a thrill felt 
in certain valvular diseases, and occasionally tactile fremitus will be an 
aid in diagnosis. Bony rachitic changes as the rickety rosary or 
Harrison's groove are identified by the examination with the hands. 

The right hand on the abdomen feels for the lower border of the 
liver, while the left may palpate the spleen. If this is palpable in a 
child, it is said to be enlarged. The liver in infants when in the prone 
position is normally about one inch below the free border of the ribs. 
In the erect position in the infant it may touch the crest of the ihum. 
Tumors in the abdomen and an enlarged kidney as in pyelonephrosis 
can be palpated. 



46 



DISEASES OF CHILDREN. 



The hip-joints and the knee-joints are examined for mobility. 
Pain, if elicited over the tibia, may assist in establishing the diagnosis 
of scurvy. The ankle and feet are examined for signs of edema and 
fiat-foot. The lower extremities are approximated, and any abnor- 
malities in outline such as knock-knee or bow-legs will then be readily 
appreciated. 

The child is now induced to walk, and if postural defects warrant 
it a detailed examination of the spine for scoliosis or Pott's disease is 
made. 




Fig. 12. — Correct position of holding an infant for auscultation. 

The patellar reflex may be tested by raising the thigh from the 
table and allowing the leg to hang limply. A smart tap over the ten- 
don below the patella should elicit a ready response. In older children 
it may be necessary to distract their attention by asking them to look 
at the ceiling or pull their interlocked fingers apart while the test is 
being made. 

Kernig's sign, or the inability to easily extend the leg after flexion 
on the thigh, is a valuable sign of meningeal irritation, and this test 
should be made if there is any suspicion of meningeal or cerebral 
involvement. 



THE EXAMINATION OF THE SICK CHILD. 47 

The Babinski reflex or the hyperextension of the great toe and 
a flexion of the remaining toes, is elicited when the plantar surface of 
the foot is irritated by drawing the finger-nail across it. This sign 
is of value only after the second year of life, since it may be elicited 
in perfectly normal infants. Rectal examination should be made if 
abdominal conditions warrant or need further corroboration. 

Auscultation. — This should preferably follow palpation or some- 
times, if expedient, the inspection. Infants should be held in the 
arms of the mother or nurse, against her left shoulder with the in- 
fant's back to the examiner, as illustrated in Fig. 12.^ 

A stethoscope with a small bell is quite necessary, as the ear 
cannot advantageously be placed, for example, in the axilla of an 
infant. Children are best examined seated upon a table. The 



Fig. 13. — Pisek's reversible stethoscope. 

stethoscope is alternately passed from side to side in a line parallel 
to the spine, then the infrascapular region is auscultated, then in the 
axillary line on either side, beginning well up in the axilla, with the 
arms raised above the head. 

The front of the chest is gone over in a similar manner. The 
examiner should recollect that the lungs in an infant on the left side 
posteriorly reach to the eleventh rib; on the right side posteriorly, 
to the lower border of the ninth rib. In front, on the right side to the 
fourth or fifth rib and on the left side to the ninth or tenth rib. 

Auscultation of the heart sounds is made at the apex, at the base, 
and at the second right intercostal space; if any murmurs are present 
they are traced along the lines of intensity. 

The examiner must accustom himself to pick out the normal 
breath sounds while the child is crying. After he becomes expert he 
will almost prefer that the child cries while he is auscultating. So- 
called puerile breathing, that is, exaggerated normal vesicular breath- 
ing, is to be expected. 

It must further be recollected that the chest wall is thin, and the 
sounds within are therefore more readily transmitted to the ear. 

Percussion. — This should be accomplished with a sudden light 
tap because of the thin wall and the elasticity of the ribs. Percuss 
alternately from side to side, preferably first over the dorsum of the 



48 DISEASES OF CHILDREN. 

chest, then the anterior surface of the lungs, and finally the area of the 
heart may be mapped out. 

To do this begin your percussion near the clavicle and percuss 
downward until the note changes at the base of the heart. Make 
your line here with a flesh pencil. The right border of the heart is 
found by beginning the percussion well to the right of the sternum 
and mapping out this border to the apex. The left side is similarly 
found, by beginning the percussion from the axillary side. The apex 
beat may be located both by palpation and auscultation. 

The area of absolute heart dullness is relatively small in infants, but 
the fact that the lungs do not overlap the heart as they do in the adult 
should not be forgotten in percussing for the relative dullness. Per- 
cussion over the abdomen may be made, to obtain the lower border 
of the stomach, or a distended colon, for free fluid in the abdomen, 
a distended urinary bladder, partial intestinal collapse, or appendicial 
abscess. In cerebral cases in which fluid is suspected in the ventricles 
Macewen's sign should be sought for; this consists of a tympanitic 
note heard over the parietal area when the ventricles are distended 
as in hydrocephalus or in certain cases of meningitis. 

Mensuration. — The weight should be recorded in infants once 
or twice a week, in older children, each time they are brought to the 
physician so that he may judge of the progress of their general develop- 
ment. For infants a weight chart, such as has been devised by 
Dr. W. L. Carr, is useful (Fig. 14). The standing height should be 
occasionally taken and compared to the weight. (See diagrammatic 
table, page 32, for normal relations.) The circumference of the head 
and chest and their relations to each other give valuable data as to 
disease conditions or to defects in physical development. The tape 
used should be made of nonstretchable linen or steel. If on auscul- 
tation or percussion signs of fluid in the chest have been obtained, the 
tape measure may show the affected side of the chest to be greater 
than the other. Mensuration of an atropic extremity or muscle 
groups are made in cases of infantile paralysis or in the dystrophies. 

Rectal Examination. — The rectum and sacrum in infants and 
children is almost straight, and because of the shallow pelvis, the so- 
called ^^ pelvic organs" of the adult are found to be partly or wholly 
abdominal in the infant and child. 

The index-finger in the case of the child, or the little finger in the 
infant, can be used, and with the help of the other hand, bimanual 
examination is easily made. The abdominal wall is usually thin and 
offers little or no resistance to the palpating finger. As a rule, no anes- 
thetic is required, as the sphincter relaxes easily and the discomfort 



PLATE IV. 




Illustrating topographical anatomy of the lungs and the lobes, also 
position of the heart and relations of the bronchi. 



PLATE V. 




Showing position of lower border of the lungs and the position of the kidneys. 



THE EX.\MIXATIOX OF THE SICK CHILD. 



49 



is temporary. The child should he on its back with hips elevated 
and the thighs flexed on the abdomen. The examiner standing on the 
right side of the patient explores ^ith the well-lubricated finger of the 
right hand; using ths left hand for abdominal palpation. The opera- 



WEIGHT IN GRAMS. 



i S - 


3i|§i§§3ggi£ 


?si§s§oi^gs 


s_ 


1 














1 












































































1 1 ■ 












































-r,= 


















































; 


1 








































§ 




: i 


! . 








































■■M 


! ' '■ 


1 










































'i! 












































"s 
















































1 












































' I , 












































S^ 


1 : 


























































































■ 1 














































: 1 












































n'" 














































'».. 
















































1 ■ 


























































































si" 














































'=r. 










































































































































«' 














































■^ 






























































































' 1 


























































































5 








































































































































rn o- 












































^ -*, 






























1 














Hi ? 














































u - 














































^ ;-- 




























i 


' 
















z s 




































































1 ' 


1 ' 


1 1 1 


1 1 
















111 - 














































O «i" 












































1 


< "_ 










































































































































<K^ 






























































































' 


"! 1 1 


' 






















































































"*■'* 




; ' 




















\ 




















^'c 




























V 




























1 


















\ 


















N 














































«■' 






























"\ 
















































. 














00 
































V 












1 1 


— 
































\ 












1 ' 


o- 












































' 1 1 


1- 


































\, 










- li 


~ 


































\ 










1 i 


— 


































V 












ei 
















































1 ; 


































\ 




, 


, 




— 


1 ; 


































\ 










— 








1 




























1 


I 


' 1 




1 


QC 


1 • 












































1 1 




































\^ 


1 1 




' 1 1 


• •" 


n 




































y 












1 


































\^ 










i 1 1 


1 i 1 


































\ 












1 1 1 




































\ 




1 


■ 


I'i 


I , ] 




































J 




1 1 






1 ■ ' 




































*y 




1 1- 




1 1 1 






































y , 




1 


; 


1^1 




5^5 




5^1 




5?^ 

3 ^s 


iV) 


r^i 




r^si 


2^- 


5 ^ ; 




5« ; 




=^ 










5 ^^ 






•SONnOd Nl 1H0I3M 



tion is reversed for the left side of the body. Any abnormahties, 

new-growths, or diseased conditions of the structures and viscera in 

the lower abdomen can then be palpated and much information gained. 

In cases of tuberculous peritonitis the abnormal omental thick- 

4 



50 DISEASES OF CHILDREN. 

ening and the matting of the intestines can often well be made out, 
the diagnosis thus confirmed, and the prognosis made more definite. 
Enlarged mesenteric and retroperitoneal glands are palpable by a 
sweeping motion of the introduced finger without the necessity of 
changing hands. 

Intraabdominal sarcomata can be quite definitely located; calculi 
in the bladder or ureters palpated, malformations of the kidneys or 
enlarged kidneys, as in hydro-, or pyonephrosis may be distinguished. 

Therefore, in an abdominal case where the diagnosis is not abso- 
lutely clear and uncomplicated, the examiner should not pass judg- 
ment upon a given case without recourse to a thorough examination 
through the rectum. 



CHAPTER VII. 
SPECIAL EXAMINATIONS. 

Exudates. — A culture and a smear should be made for examina- 
tion if the throat, e.g., shows a suspicious membrane or if there is a 
serosanguinolent discharge from the nares. A sterile cotton applicator 
is swabbed over the area and gently wiped over the culture medium 
and upon a clean glass slide. 

The laboratory examination of these exudates is most important 
in differentiating diphtheria from other infections of the nose and 
throat. In making a positive morphological diagnosis of the diph- 
theria bacillus (Klebs-Loeffler) certain very definite conditions must 
be complied with. The smear must be taken from the nasopharynx 
or laryngeal region. It must be grown upon a special media (blood 
serum), and it is best that it should not be grown for much more than 
sixteen hours at incubator temperature. Under these conditions the 
bacilli (if they are the Klebs-Loeffler) must show a certain morph- 
ology. Their characteristics are a long slender bacillus with clubbed 
ends, w^hich stain very irregularly and often show deeply staining polar 
granules. 

It is not uncommon for the first, and even for the second smear to 
be negative in a case which afterwards becomes positive. This fact is 
explained in two ways. Many sore throats start out as a mixed infec- 
tion, staphylococci or streptococci predominating in the early stages. 
Under these conditions it is sometimes difficult to determine how much 
weight to give to a few bacilli which look diphtheritic when the vast 
majorit}^ of the organisms present are cocci. A safe rule in such 
circumstances is to regard it as doubtful and to give an injection of 
diphtheria antitoxin. A second cause for a negative smear is in 
diphtheria of the nasopharynx or larynx which is overlooked, the 
smear being taken from some place in the throat which happens to 
be clear of infection or which has been treated with disinfectants. 

A purulent secretion from the eyes may demonstrate on smear the 
presence of the Koch- Weeks bacillus or the gonococcus of Neisser. 
A similar test of a vaginal or urethral discharge may be necessary to 
determine the character of the contagion and to determine upon the 
necessary precautionary measures. 

51 



52 DISEASES OF CHILDREN. 

The sputum. — The examination of the sputum in infants and very 
young children is not satisfactory, owing to the difficulty of obtaining 
a satisfactory specimen. This may in a measure be overcome by 
passing a stomach tube into the first part of the esophagus — the tube 
as a rule bringing up some secretion. A more agreeable method is to 
pass a cotton swab on a long sharply bent probe into the larynx. In 
order to do this the epiglottis must be held forward as is done in pass- 
ing a lar}^ngeal tube. Smears made from sputum obtained in this way 
will occasionally show tubercle bacilli. In lobar pneumonia it is some- 
times possible to demonstrate rusty sputum in this way. The pneumo- 
coccus and influenza bacilli, can be found in such a smear. 

Gangrene of the lungs is characterized by the offensive odor and 
by the color and fluidity of the sputum. Such sputum will separate 
into layers, with a thick brownish deposit at the bottom, a clear fluid 
in the middle, and a frothy layer on the top. 

When an empyema ruptures into the lungs the sputum is com- 
posed almost entirely of pus, and is thin and liquid. 

In those cases where bronchiectatic cavities have formed, the 
sputum is abundant and thin, and on standing separates into a layer 
of pus and one of mucus. If the cavities are large, putrefaction can 
take place, and large amounts of thin, foul-smelling gray-green fluid 
may be coughed up. 

The Gastric Contents. — The examination of the gastric juices in 
infants and small children has not developed any special diagnostic 
features of importance. Much can be learned in this way as regards 
gastric motility, but aside from this such examinations have an aston- 
ishingly small value. 

The Feces. — It is certain that the feces are not examined as fre- 
quently as they ought to be. Much can be learned regarding the well- 
being of the infant and the small child by a systematic inspection of 
the stools. As a rule the whole stool is not necessary, one or two 
drams being a sufficient amount. The examination should be made 
as promptly after the passage as is possible, as the stool undergoes 
putrefactive and fermentative changes if allowed to stand. In examin- 
ing for ova an old stool may be used. 

The reaction of the stool of course changes rapidly on standing. 
In a general way it may be said that a strongly alkaline reaction in 
feces which have recently been passed, suggests protein putrefaction, 
and that an acid reaction points towards a disturbance in the diges- 
tion of the fats. 

An excess of muscle fiber, connective tissue or vegetable fiber can 
be determined by placing a small piece of the stool under the micro- 



SPECIAL EXAMINATIONS. 53 

scope. If Lugol's solution is added, the starch granules are stained 
blue or violet. There should be practically no unchanged starch in the 
normal stool. An alcoholic solution of Sudan III or scharlack R stains 
fat globules red, and the fatty acids a somewhat lighter color. The 
casein is soluble in a 5 per cent, solution of HCl or in a little acetic acid, 
and is hardened by the addition of formalin. Coagula composed of 
casein, or of mucus plus fat, fatty acids and insoluble soaps are some- 
times found in the stools of infants. Most of these coagula are of the 
latter type, though occasionally true casein curds are present in the 
stools. The point can, as a rule, be quickly determined by shaking out 
a few of the masses in ether — those due to fatty acids, soaps, etc., are 
dissolved by the fats going into solution with the ether. 

Blood in the feces can be identified by adding 10 drops of freshly 
prepared alcoholic solution of resin guaiac and 30 drops of ozoned (old) 
turpentine to an ethereal extract of the stool. Another method is to 
dissolve a few granules of benzidine in 2 c.c. of glacial acetic acid. A 
small fragment of the stool is mixed w4th 2 c.c. of water and boiled. 
Ten drops of benzidin-acetic acid solution and 3 c.c. of a 3 per cent, hy- 
drogen peroxide solution are mixed in a test-tube and a few drops of the 
cooked emulsion of feces are added. 

In both these tests a greenish or bluish color shows the presence of 
blood. The benzidin test is extremely delicate, and may be positive 
if the patient is eating meat. 

Ova. — Any of the cestoda may exist in the intestinal tract of 
children. Their identification depends upon finding the ova in the stool 
■ — as a rule not a difficult matter with the more common forms, though 
during the earlier stages of the infection a long and careful search 
must be made. 

The Cerebrospinal Fluid. — The examination of the spinal fluid 
has great diagnostic value. It should be collected with absolute 
surgical cleanliness so that if necessary cultures on blood serum can 
be made; and care should be taken not to get a '^bloody" puncture, 
for even the smallest quantity of blood obscures the macroscopic ap- 
pearance of the fluid, and also makes a cytological examination 
impossible. 

In meningitis there is always an exudate of cells, which makes 
the fluid more or less cloudy. In tuberculous meningitis the cellular 
exudate is sometimes so slight that the fluid appears clear unless 
carefully examined. 

A preponderance of polynuclear leukocytes in the exudate de- 
notes a non-tuberculous meningitis, except in the early stages of the 
disease when they may be present in large numbers. On the other 



54 DISEASES OF CHILDREN. 

hand, when a majority of the cells are either large or small lymphocytes, 
tubercle bacilli should be looked for. Syphilitic fluids as a rule show 
a relatively large percentage of lymphocytes. 

In epidemic spinal meningitis it is always possible to find the 
diplococcus intracellularis. In the earlier stages of the disease they 
are more easily found than later; and a few days after the injection of 
Flexner's serum it may be almost impossible to find them. They are 
gram-negative, and intracellular. Occasionally an acute meningitis 
is caused by the pneumococcus, influenza bacillus and still more rarely 
by other organisms, such as typhoid bacilli. The diagnosis of these 
latter conditions depend upon cultures and the agglutination tests. 

To find the tubercle bacilli in the spinal fluid often requires hours 
of patient search. If the fluid is allowed to stand for a short time there 
appears at the center a thin film of fibrin. This should, be removed 
and dried on a cover slip. The fluid itself should be centrifuged for 
one-half to one hour at 2,500 revolutions per minute, and the sediment 
dried on the same cover slip as is the fibrin. After staining it is 
possible to demonstrate in nearly 100 per cent, of the cases the Bacillus 
tuberculosus. The diagnosis can also be made by inoculating a little 
of the sediment into a guinea-pig. 

A Wassermann reaction may also be made with spinal fluid, and 
it is apparently as dependable as when blood serum is used. (See also 
page 65.) 

Noguchi has devised a method whi(5h may prove applicable to 
some of the ill-defined inflammatory conditions of the meninges, such 
as the so-called serous meningitis in which micro-organisms and 
inflammatory cells cannot as a rule be demonstrated. The method is 
as follows: 

To one or two parts of cerebrospinal fluid are added five parts of a 10 per 
cent, butyric acid solution in a physiologic salt solution. This is boiled for a 
brief period. One part of a normal solution of NaOH is then quickly added, and 
the whole boiled once more for a few seconds. 

The increased amount of protein in the cerebrospinal fluid is 
indicated by the appearance of a granular or flocculent precipitate. 
Normal cerebrospinal fluid gives a slight opalescence or sometimes a 
turbidity, but not a granular precipitate, unless aflowed to stand for a 
number of hours. This test is positive in syphilitic and parasyphilitic 
conditions, and in all cases of inflammations of the meninges caused 
by micro-organisms. It suffices to distinguish normal from patho- 
logical cerebrospinal fluid, and especially that form of pathological 
fluid which is altered through an increase in its protein content. 

Cerebrospinal fluid often contains a sugar reducing agent, but this 



SPECIAL EXAMINATIONS. 



55 



condition is of no diagnostic value so far as is known at the present 
time. 

Technic for Subdural or Lumbar Puncture. — One of two positions 
may be selected: the sitting posture, or the child may be placed on 
its side with the spinal column well flexed. Cleanse the lower 
lumbar area until the parts are surgically clean. The operator, 
who has thoroughly cleansed his hands then takes the sterilized 
needle in his right hand, as one holds a pencil in writing, and in- 




FiG. 15. — Method of performing subdural or lumbar puncture. 

serts the same at right angles to the body through the skin and soft 
parts between the third and fourth lumbar vertebrae (see Plate II). 
This point is conveniently located by placing the index- and third 
fingers of the left hand on the highest points of the respective iliac 
crests, the middle finger being placed on the vertebral spine w^hich 
is on the same level as the crests above determined. This is the third 
lumbar spine, and the point of election is midway between this spine 
and the one immediately below it. The needle meets with only carti- 
laginous resistance if properly inserted, and should be introduced about 
three-quarters of an inch. If bony resistance is encountered, with- 



56 DISEASES OF CHILDREN. 

draw slightly (not entirely) and change somewhat the angle of inser- 
tion. If the spinal canal is entered a free flow of fluid follows; then 
allow the fluid to escape into a sterile tube. At the same time collect 
two or three drops in a culture tube of blood serum. When 15 c.c. 
have been collected quickly withdraw the needle and seal the punc- 
ture wound with cotton and collodion. 



Technic for Aspiration of Pleural Cavity. 

Aspirated fluid from the chest when slightly clouded is micro- 
scopically examined for the presence of pus-cells, and operative inter- 
ference is often based on their numerical estimate. 

Sterilize a needle and clean the chest wall over the site of election, 
in all cases observing strict surgical asepsis. 

Place the child in a sitting posture with both arms drawn well 
forward then, holding the needle at a right angle to the body, puncture 
in the midscapular or in the posterior axillary line (preferably the 
former), the point of election being the interspace just below the 
angle of the scapula. Insert the needle about three-quarters of an 
inch. From the fluid a culture is made and the remainder is collected 
in an empty sterile tube for further examination. Seal the puncture 
wound with cotton and collodion. 

The Urine. 

Only the more important diagnostic features of urinary analysis 
will be touched upon. The subject has a great practical interest not 
only for the diagnosis of kidney lesions, but also for the recognition of 
changes in other organs. 

The specimen should as far as possible be a part of the whole 24- 
hour urine, in order to avoid the well-known variations in the specific 
gravity, the reaction and other properties of the urine. For micro- 
scopical examination it is important to have a fresh specimen as de- 
composition may change the entire picture within a few hours. Fer- 
mentation sometimes results in the entire disappearance of small 
amounts of sugar and greatly reduces the total percentage where it is 
present in larger quantities. All such changes may at least be delayed 
by keeping the urine in the ice-box or by the addition of small amounts 
of salicylic acid, thymol, chloroform or chloral. 

Quantity. — Infants pass a relatively larger amount of urine than 
do older children and adults. Furthermore, the quantity fluctuates 
widely from day to day, according to the amount of fluid food taken 



PLATE I. 



war; 
h:o< 



rv 



\r 




(V 



ir 




crcc 



SPECIAL EXAMIXATIOXS. 57 

and the activity of the bowels and the skin. The average amount 
passed during the first week of life is from three to twelve ounces a 
day, and during the first two months from five to thirteen ounces. 
From this time up to the end of the second year the quantity of urine 
passed gradually increases, so that the average is from eight to twenty 
ounces. Between thirty and fifty ounces of urine are passed daily 
from the eighth to the fourteenth year. 

During the first two years the urine is passed as often as twice in 
the hour when the child is awake, but during sleep is retained from 
two to six hours. A fair control of the sphincters of the bladder is 
often obtained at two years, and sometimes at an even earlier period. 

The specific gravity during the first eight years of life averages 
1008-1012. Microscopically the urine normally contains epithelial 
cells, mucus, granular matter, crystals of uric acid, amorphous and 
crystalline urates and the amorphous and crystalline inorganic salts. 
AVhen prolonged and very careful examinations are made, hyaline and 
even an occasional hyalo-granular cast may be found in the urine 
of healthy infants. 

Sugar in minute quantity is not infrequently present during the 
first two months; and traces of albumin have been observed in a 
fairly large number of cases. 

Test for Indican. 

The simplest and probably the most accurate test for indican in 
urine is performed as follows: to a clean test-tube add four to six drops 
of a 1 per cent, solution of potassium permanganate, then 1 or 2 c.c. 
of chloroform, then 10 c.c. of concentrated hydrochloric acid C. P., 
and lastly 10 c.c. of urine. Invert the test-tube two or three times to 
thoroughly mix and allow to stand five minutes. The ethereal sul- 
phates in the urine are broken down by the hydrochloric acid and 
are oxidized by the potassium permanganate to indigo which is dis- 
solved by the chloroform, giving a deep blue color, the intensity 
of which when compared with the color scale (Plate III) determines 
the extent of the putrefactive changes occurring in the intestine. 

The presence or absence of indican in the urine is important, as 
its presence indicates an excessive putrefaction of the protein substances 
in the intestines. The test can also be made by placing an equal 
amount of urine and hydrochloric acid in a test-tube to which is added 
one drop of peroxide of hydrogen. If much indican is present a dark 
blue or purple color is produced, which may be shaken out with 
chloroform. The reaction may not appear at first but may come out 



58 DISEASES OF CHILDREN. 

after standing for a time. If more than one drop of hydrogen-peroxide 
is added the blue color may be bleached. In alkaline urine the indican 
is usually destroyed. 



Thread Reaction in Pyelitis. 

Pfaundler demonstrated ^Hhat a bouillon culture of bacilli grown 
on urine and mixed with the blood serum of the same patient will 
produce, even when considerably diluted, an agglutination" such as 
occurs in other bacillus coli infections. 

The bacteria to be examined are grown oh agar-agar, a twenty- 
four hour culture being employed. Three drops from the (water of 
condensation) culture are added to a bouillon tube. This emulsion 
is mixed with the patient's serum in the proportion of one to thirty 
or one to fifty, and then examined in the hanging drop. After twenty- 
four hours if the reaction is positive the following appearances develop : 
" The small rods grow out into delicate extremely long threads which 
apipear claw-like and interwoven, and form lumpy groups under slight 
magnification. The groups are either isolated or else are connected 
by extremely delicate filaments. Between the single filaments the 
liquid is perfectly free from form element. The threads and filaments 
do not present the least indication of mobility. Under high powers 
the threads appear partly articulated, granular and sometimes thick- 
ened with clubs. The threads are greatest in length, and the filaments 
are densest in the reaction where the serum dilution is the least." 

To produce this reaction the necessary conditions are: 'Hhe 
employment of a serum of microbes from the same patient and the 
presence of fever during the infection as an indication of the general 
disturbances; the reaction, however, fails not only in light cases of 
brief duration, but in serious cases which end in death." 



Transudates and Exudates. 

Rivalta has recently perfected a test for accurately distinguishing 
between transudates and exudates. 

Add 2 drops of acid acetic (glacial) to 100 c.c. of water to make the 
test solution. Allow the exudate, a drop at a time, to make its way 
down through the dilute acid medium and it will leave a bluish trail 
in the water like a puff of cigarette smoke, each drop leaving a sepa- 
rate trail. The fluid remains clear and unaltered if the added drop be 
that of a transudate. 



SPECIAL EXAMINATIONS. 59 

The Roentgen Rays. 

The X-rays are of late assuming a greater importance in pedi- 
atric practice. Foreign bodies swallowed or aspirated, fractures and dis- 
locations, bone changes and tumors, estimation of anatomic age, dis- 
placed viscera, consolidations and exudations are conditions in which 
we can obtain valuable aid. Short exposures should be made with the 
best tubes. An anesthetic is sometimes necessary for unruly children. 

Hemoglobin. 

The quantitative determination of hemoglobin must be made 
with fresh blood, whatever the method used. The Tallqvist hemo- 
giobinometer is the cheapest and simplest instrument on the market, 
consisting merely of a color scale and special filter-paper. The blood 
is absorbed by a small piece of the filter-paper, and after the glazed 
surface has disappeared by the blood soaking into the paper, the spot 
is compared with the various colors of the scale in daylight, until the 
shade is approximately matched. The error of this method is about 5 
per cent. This error may be reduced by taking care to have the drop 
of blood on the filter-paper at least twice as large as the ring through 
which the comparison of the colors is made. 

The Dare hemogiobinometer is a simple and satisfactory instru- 
ment, but is expensive and easily broken. It has the advantage that 
it may be read by artificial light. In this instrument the fresh blood 
is compared with a colored glass picture wedge. With practice the 
error of the instrument is less than 5 per cent. 

The Fleischl-Miescher hemogiobinometer is expensive and rather 
difficult to use, but probably is the most accurate instrument at our 
command and is generally found in well-equipped laboratories. 

For the first few days after birth the hemoglobin percentage is 
high, and then sinks so that it is lower in the first year of life than 
later, according to Perlin varying from 58 to 78 per cent, by the Fleischl- 
Miescher hemogiobinometer. After the nursing period, it gradually 
rises to 75-85 per cent, in the sixth year, reaching the average for 
adults at about the tenth year. 

Red and White Blood Counts. 

In making the red and white count, fresh blood must be used. 
The blood is drawn into a pipette and diluted 1:10 for the white cells 



60 



DISEASES OF CHILDREN. 



and 1 :100 for the red cells. It is best to make the count immediately, 
but by passing a rubber band around the ends of the pipette it may 
be carried for some time, especially if Hayem's* solution is used. The 
error in counting the red cells in one hundred squares is 5 per cent, or 
over. To reduce this error to 3 per cent., 400 squares should be 
counted. In the white blood count 200 leukocytes must be counted 
to bring the error under 5 per cent. 

Red Cell Count in Early Life. 

In early life the average number of red blood-cells is somewhat 
higher than in the adult. During the nursing period it averages about 
5,580,000, with a maximum during the first week of life. In the second 
year the number is about 5,680,000, and from the second to the sixth 
year the average is rarely under 5,900,000, girls showing a slightly 
lower count than boys. In infants and young children from day to 
day a fluctuation of a million cells may occasionally be found. 

White Cell Count. 

The white cell count in infants and young children is very dif- 
ferent from that of the adult, as may be seen from the following table: 



Age 


Average number of 
leukocytes 


Maximum num- 
ber of 
leukocytes 


Minimum number 

of 

leukocytes 


At birth 


15,000-19,000 
12,000 
9,000 
7,000 






Nursing period 

1-6 years 

6-13 years 


16,000 
13,000 
12,000 


8,600 
6,900 
5,400 



The blood of children is much more sensitive to stimuli than is 
the case in adults, so that there is occasionally a very high leukocytosis, 
from a small cause, as for instance a leukocytosis during digestion of 
20,000-25,000. Any increase in the leukocytes over the maximum 
given in the table above is to be looked upon as pathological and at 
least requires an explanation. 

A well-marked (polynuclear) leukocytosis is to be expected in 

* Mercuric chloride, 0.5 gram; sodium sulphate, 5 grams; sodium chloride, 1 
gram. Aq. dest 200 c.c. 



SPECIAL EXAMIXATIOXS. 



61 



scarlet fever, erysipelas, diphtheria, pneumonia, acute articular rheu- 
matism, tuberculous meningitis, and suppurative conditions. There 
is only a slight leukocytosis in typhoid, roetheln, mumps, malaria, 
and uncomplicated tuberculosis, except when it invades the meninges 
or serous surfaces, or when it becomes complicated with a septic 
condition. There is also a high (lymphatic or myelogenous) leukocy- 
tosis in the leukemias. A moderate (polynuclear) leukocytosis is 
frequently present after ether or chloroform inhalation, after taking 
quinine, the salicylates, tuberculin injections, and following saline 
infusions. Even more important than the leukocyte count is the mak- 
ing of a differential count. 




Fig. 16. — Method of makino; blood smear. 



Blood Smears. — An important point in making a good smear is to 
have a clean slide. If new slides are used it is usually sufficient to 
breathe on them and polish them off with a dry towel, but old slides 
must first be cleaned with acid. One end of a slide is just touched to a 
drop of blood, and this slide is then gently touched to the surface of 
another slide at an angle of about 30 degrees. The first or smearing 
slide is then gently drawn over the surface of the slide on which the 
smear is being made, thus dragging the blood out in a broad thin 
film which quickly dries. The size of the drop and the speed with 



62 



DISEASES OF CHILDREN. 



which the smear is made determine the thickness of the preparation, 
and not the pressure, which should always be light. Such a smear is 
used for studying the morphology of the blood-cells, in the search 
for malaria plasmodia, and in some regions for parasites (filaria, bil- 
harzia, etc.). 

Nucleated Red Cells in Infants. — In infants up to the eighth month 
it is possible to find an occasional nucleated red cell, which may be 
either the size of a normalred cell or from two to four times larger. 

The Relation of Neutrophiles to Lymphocytes during Childhood. — 
The relation of the neutrophiles to the lymphocytes during childhood 
is shown in the following table: 



Age 



Neutro'3hiles 



Lymphocytes 



Nursing period. . . 
8th-10th month:. 
After 10th month 

2d year 

6th-8th year 

10th-14th year... 




51-59% 

56-61% 

56% 

55% 
41% 
30% 



The increase in neutrophiles occurs chiefly in the second, third, 
and fourth years, but an increase is noticeable up to the fifteenth year. 

The diseases in which there is or may be an increase of neutro- 
philes (polynuclears) leukocytes have already been discussed under 
leukocytosis and, therefore, it is only necessary at this point to indi- 
cate those conditions in which the leukocytosis is due to the increase 
of other cellular elements. The lymphocytes in typhoid are relatively 
increased, but emphasis should be placed on the fact that the total 
number of leukocytes are decreased, so that the white count in this 
condition will vary from 3,000-4,000. The increase in lymphocytes 
is chiefly important in the leukemias — a rare condition in children and 
when present usually of the chronic lymphatic variety. The diagnosis 
of the condition depends upon repeated leukocyte counts of 30,000 
(generally 100,000) or more, made up almost entirely of lymphocytes, 
or myelocytes and lymphocytes. Von Jaksch's anemia or infantile 
pseudoleukemia resembles both pernicious anemia and leukemia. It 
is characterized by a marked anemia, enlarged spleen and (occasion- 
ally) liver, enlargement of the lymph nodes, and by an increase in the 
leukocytes to 20,000 or 50,000 (rarely 100,000) per cubic millimeter. 
There are many nucleated red cells of both the normoblastic and mega- 



SPECIAL EXAMIXATIOXS. 63 

blastic type. The leukocytes are chiefly mononuclear in form, and 
myelocytes are present in moderate numbers. It is probably a severe 
form of secondary anemia. 

Eosinophilia. — The eosinophiles average in health from 2 to 
4 per cent, of the total white cell count. In infancy, according to 
Wood, the maximum is 7.5 per cent, and the minimum 0.5 per cent. 
The same authority states that during childhood the maximum is 
12.5 per cent, and the minimum 0.7 per cent. In bronchial asthma 
there may be an eosinophilia of 10 to 30, or even 50 per cent. Sclero- 
derma has been known to give an increase to 10 per cent. Intestinal 
parasites sometimes cause an eosinophilia as high as 75 per cent., 
especially in the early stages of the infection, only to fall back to 
normal or nearly normal later. In scarlet fever a moderate eosino- 
philia is present, in contrast to measles in which no such phenomenon 
is observed. 

Malaria. — The diagnosis of malaria can be made by finding the 
Plasmodia in the blood. These plasmodia are present in largest 
numbers just previous to or at the time of the chill, but in the quartan 
and tertian types a few may be found at any time. In the estivo- 
autumnal form of malaria it is often necessary to search for a long time 
before the plasmodia are found. In some cases of malignant malaria 
(black-water fever) the plasmodia disappear entirely from the per- 
ipheral circulation. Even one-half of a gram of quinine is sufficient 
to nullify a most careful search for the plasmodia, so that a negative 
result under these circumstances is of little value. 



The Widal Test for Typhoid. 

Preparation of Blood. — In making a Widal test either a dried 
specimen of the blood may be used or, better still, the serum. In ob- 
taining a dried specimen of blood the finger is pricked with a needle, 
preferably a Hagedorn needle, and a very small drop of blood is placed 
on a clean slide and allowed to dry. Several such drops should be 
niade in order to give the pathologist a choice and also to avoid los- 
mg the specimen through error or breakage. Blood serum is to be 
preferred because it is more accurate for the making of dilutions. The 
method of collecting the blood is the same as that described later under 
the Wassermann-Noguchi test. 

Dilutions. — The pathologist should always state the dilution made, 
and if there is a positive result with 1:20 a dilution of 1:40 and 1:60 
should be tried. Rarely there is a positive result in dilutions of 1:20 



64 DISEASES OF CHILDREN. 

in normal blood. With dilutions of 1 : 60 for one hour Wood obtained 
only 10 per cent, of positive results during the first week, but many of 
these cases gave good agglutinations in one hour in dilutions of 1 : 20. 
In the second week the reaction was present in about 80 per cent, of 
the cases, using a dilution of 1:60 for one hour. During the fourth 
week 8 to 9 per cent, more of these cases gave positive results. Taking 
the whole course of the disease, only 1-2 per cent, of the cases failed to 
react when the blood was frequently tested. Agglutinations to this 
degree, e.g., 1 : 60 for one hour, may be present for only a few days and 
then become weaker. Libman states that he has never failed to 
obtain a positive reaction some time during the course of the disease, 
using a dilution of 1:20. 

The Widal reaction appears so late in dilutions which are abso- 
lutely diagnostic that it is of little value in the early diagnosis of an 
active and well-marked typhoid. If, however, the clinician is in a 
position to interpret the test, very suggestive results are often obtained 
during the first week. A Widal has a great value in the diagnosis of 
obscure or ambulent cases, and in children where the symptoms refer- 
able to the intestinal lesion are not prominent. 



Tuberculin Tests (see also p. 349). 

One of three tests may be selected for use in suspected tuber- 
culous children. The skin test was superceded by the eye test and 
inunction test, but to-day it has the greatest number of advocates, 
since it is the most reliable and at the same time least annoying to 
the patient. 



Skin or Von Pirquet Test. (Plate II.) 

This is made by scarifying three small areas on the arm, as for 
vaccination, and inoculating the central one with a drop of Koch's 
old tuberculin (obtainable in the market), using the upper and lower 
areas as controls. In from twelve to forty-eight hours (occasionally 
even longer) a reaction will be observed in tuberculous individuals. 
At first a reddened blush appears w^hich soon becomes inflamed and 
resembles the first stages of a successful vaccination. The controls 
should show no reaction. In advanced cases the reaction usually 
fails, due to the presence of numerous antibodies in the blood of the 
child. 



PLATE II. 




The ocular, percutaneous and cutaneous tests, (a) ocular reaction; (,6) 
inunction or Moro reaction: (c) cutaneous or Von Pirquet reaction. 



SPECIAL EXAMINATIONS. 65 

The Calmette or Eye Test. (Plate II.) 

In selected cases in which we are positive that the eye is normal, 
one drop of a 1 per cent, solution of tuberculin for older children and 
a 1/2 per cent, for infants, is dropped on the lower lid of one eye and 
the eyelid held down for a moment before allowing the eye to close; 
the closure should not be spasmodic, but gentle; it is better to gently 
massage the eyelids over the eyeball for a moment. 

A positive reaction is indicated by a feeling of annoyance in the 
eye which ensues in from six to twenty-four hours, or even after two 
days. The palpebral or ocular conjunctiva becomes injected, later the 
caruncle is swollen, and, in intense reactions, an exudate is observed. 
The patient complains of having a ^' cold in the eye." The symptoms 
soon diminish, so that in four to five days the eye is quite normal 
again. 

The indiscriminate use of this test has led to reports of corneal 
ulceration. The severity of the reaction is no criterion for the in- 
tensity of the infection. Severe reactions may follow in incipient 
cases. As in the skin test, active and latent cases will react, but those 
far advanced may give a negative test. It should be remembered 
that no immunity to tuberculin is produced by these tests; the other 
eye will react; a skin test or inunction test can be subsequently made 
in the same individual. 



The Inunction or Moro Test. (Plate II.) 

The Moro reaction is obtained by using a 50 per cent, tuberculin 
and lanolin ointment, and vigorously rubbing a piece the size of a 
split pea for a few moments over the site selected; this may be, for 
example, the axillary or the interscapular region. A maculopapular 
eruption is produced in the tuberculous at the annointed area in from 
twelve to twenty-four hours. It may persist for five days to over a 
week, and in neurotic children may appear on the opposite side of the 
body. The test is simple, easily performed and commends itself for 
use with intractable children. 



The Wassermann and Wassermann-Noguchi Reaction. 

The Wassermann and Wassermann-Noguchi tests are the applica- 
tion of the Bordet-Gengou phenomena of complement fixation to the 



66 DISEASES OF CHILDREN. 

diagnosis of syphilis. In describing this test it is first necessary to 
have clearly in mind the meaning of certain terms. An antigen is a 
substance capable of producing a specific antibody (amboceptor) when 
administered once or repeatedly (usually by injection) into a suitable 
animal. Under these conditions most albumins or protein bodies are 
antigens. For example, bacteria, bacterial extracts, blood-corpuscles, 
blood serum, milk, etc., are capable of causing the formation of anti- 
bodies, and are, therefore, antigens. On the other hand, inorganic and 
most organic substances with a definite chemical structure, when 
introduced into an animal, do not produce antibodies, and are conse- 
quently not antigens. An antibody, amboceptor or immune body pos- 
sesses a specific affinity for the antigen used in its production, and is one 
of the two active principles necessary to cause hemolysis, bacteriolysis, 
or any other cytolysis caused by serum, the other being complement. 
An antibody or amboceptor retains its activity after the serum is 
heated to from 55° to 56° centigrade for thirty minutes. Complement, 
the second of the two active principles concerned in hemolysis, bac- 
teriolysis, and other cytolysis, as opposed to amboceptor, is not 
specific, but is normally present in all sera freshly drawn from the 
body. It gradually disappears on standing or- — in contrast to ambo- 
ceptor — is completely destroyed at from 55° to 56° centigrade in 
about thirty minutes. 

In the three substances just defined are the elements of a bac- 
teriolytic system or of a hemolytic system. As an illustration typhoid 
bacilli and the serum from a known typhoid patient may be used. 
The typhoid serum contains antibody or amboceptor, and a variable 
amount of complement. This complement may be destroyed by 
heating the serum to 56° centigrade for thirty minutes and an extra- 
neous complement of tested strength be supplied by the serum of a 
suitable animal — the animal most commonly used for this purpose 
being the guinea-pig. The typhoid bacilli are the antigen; the 
heated serum of the typhoid patient contains the antibody or ambo- 
ceptor, and the complement is supplied by the guinea-pig. These 
substances when placed together form what is known as a bacteriolytic 
system. Substitute in the above red blood-corpuscles (antigen) for 
the typhoid bacilli, a serum containing a specific antibody or ambo- 
ceptor for the red blood-corpuscles, and use the same complement", 
e.g., guinea-pig serum, and the result is a hemolytic system. If the 
three parts of a system have been put together in the proper pro- 
portion and allowed to stand in an incubator from one to two hours 
it is found that all the complement has been used up or fixed in 
destroying the typhoid bacilli or the red blood-corpuscles (depending 



SPECIAL EXAMINATIONS. 67 

upon the system used). The two systems may be shown diagram- 
matically somewhat as follows: 

Bacteriolytic System. Hemolytic System. 

1. Typhoid bacilli (antigen). 1. Red blood-corpuscles (antigen). 

i i 

2. Typhoid serum. 2. Serum containing antibodies or am- 
(Taken from a known typhoid case, boceptor for red blood-corpuscles, 
and therefore known to contain anti- (Made by injecting washed red 
bodies or amboceptor for typhoid blood-corpuscles into a suitable 
bacilli.) animal.) 

I I 

3. Guinea-pig serum. 3. Guinea-pig serum. 

(Complement.) (Complement.) 



Results: a. Destruction of typhoid Results: a. Destruction of the red 

bacilli. blood-corpuscles. 

b. The using up or fixation of com- b. The using up or_/ia;a^io?i of comple- 
plement to destroy the antigen (typhoid ment to destroy the antigen (red blood 
bacilli). corpuscles). 

c. The antibody has disappeared. c. The antibody or amboceptor has 

disappeared. 

These results are dependent upon the use of definite quantities, 
and if one or two of the substances are in excess, then a diminished 
amount of these substances will remain at the end of the experiment. 

The entire process may be looked upon as a loose chemical union 
between the antigen, the antibody (amboceptor) and the complement, 
it being necessary for all the three parts to be present in order to have 
the combination take place. If the antibody is absent there is no 
union, and the complement remains free to take part in the destruc- 
tion of any other antigen which may be added, provided only that the 
specific antibody is present. Hence it is obvious that if to a bacterio- 
lytic system, after it has been allowed to stand in the incubator for 
one hour, a hemolytic system is added with the exception that the 
complement is left out, — that one of two results must take place, de- 
pending upon whether or not the supposed typhoid serum contained 
or did not contain an antibody or amboceptor for typhoid bacillus. 
If there was present an amboceptor for typhoid bacilli, the comple- 
ment would be used up in destroying the typhoid bacilli, and there 
would be none left to cause hemolysis when the two parts of the 
hemolytic system were added, e.g., the reaction would be a positive 
one. If, on the other hand, the suspected serum did not contain a spe- 
cific antibody for typhoid bacilli, bacteriolysis would not take place, 
and the complement would remain to cause a hemolysis of the red 
blood-corpuscles when they with their antibody were added, e.g., the 
reaction would be a negative one for typhoid. It is merely a question 
of whether the complement is used or not in the bacteriolytic system. 
The reaction may be diagrammatically shown as follows: 



68 



DISEASES OF CHILDREN, 



I. Bacteriolytic System. 
Antigen (typhoid bacilli). 



Hemolytic System. 
* Red-blood corpuscles (anti- 
gen). 



Complement. 
(Guinea-pig serum.) 



Amboceptor (antibody). 
(Typhoid serum.) 



Reaction is positive, because there is no hemolysis. 



* Amboceptor (antibody). 
(Specific for r. b. c.) 



II. Antigen (typhoid bacilli). 



* Red blood-corpuscles (anti- 
gen) 



Complement. 
(Guinea-pig serum.) 



(No amboceptor as serum 

is from a patient known not 

to have typhoid.) 

Reaction is negative, because there is hemolysis 



* Amboceptor (antibody) . 
(Specific for r. b. c.) 



* Added after bacteriolytic system has stood in incubator one hour. 



The Wassermann and Wassermann-Noguchi reaction are based 
upon this principle of combining a bacteriolytic and hemolytic system. 
Wassermann supposed that his antigen was an extract of the organism 
which was the cause of syphilis, and it was only when it was found that 
the extract of any liver, or indeed the extract of almost any organ rich 
in lipoids (lecethins in particular), was capable of giving a perfectly 
good antigen that this idea was given up. It is true that the extracts 
from beef hearts or from livers or from the chemical group of lecethin 
vary greatly, some forming good and others poor antigens, yet it must 
be confessed that this variability does not lie in any one group but 
rather in the organ itself, and that a very good antigen may be ob- 
tained from a beef heart and a poor one from a human liver. As a 
rule syphilitic (congenital) livers are rich in antigenic properties, but 
this is not invariably true. For this reason the Wassermann reaction 
is not in the strict sense, as it is known in other examples of the 
Bordet-Gengou phenomenon, a specific reaction. Rather the reaction 
must be viewed as a symptom of syphilis just as are the primary sore 
and the secondary rash. 



SPECIAL EXAMINATIONS. 



69 



In the actual doing of the test not only must the antigen be care- 
fully standardized but also the complement and the amboceptor. 
If there is an excess of antigen, complement, hemolytic amboceptor or 
red blood-cells beyond a certain point or if they are present in too 
small quantities the test loses its accuracy, and dependence cannot be 
placed either upon a positive or negative result. Furthermore, each 
test must be controlled with a known negative and positive serum, 
and with the serum which is being tested, in order to be sure that the 
serum itself does not cause fixation. 

The following scheme, taken from Noguchi, shows in brief out- 
line the way in which the test is made. 





Set for diagnosis. Test 


Positive control set. 


Negative control set. 










with serum in 


Test with a positive 


Test with normal 










question. 


syphilitic serum. 


serum. 








1" 


a. Unknown serum, 


a'. Positive syph. 


o". Normal se um, 1 


C 


i«; 


c^i a 


1 drop. 


serum, 1 drop. 


drop. 
b. Compliment, 2 


-C 


B ^ 


UO 


11 


b. Compliment, 2 


b. Compliment, 2 


^ 


c^-§ 


^2 


«-+!. 


O units. 


O units. 


O units. 


Q 


^- 


^-:-+^ 


gs 


c. Corpuscle susp. 


c. Corpuscle susp. 


c. Corpuscle susp. 






O c3 (i3 


P^^ 


(1 %). 1 c.c. 


(1 %), 1 c.c. 


(1 %), 1 c.c. 


^ 












f. 


■■^^ig 




a. Unknown serum, 


a'. Positive syph. 


a". Normal serum, 1 


CO 


!l 


a big 


1 drop. 


serum, 1 drop. 


drop. 




OCl 


•|§^ 


b. Compliment, 2 


b. Compliment, 2 


b. Compliment, 2 




9 5? 


S^ 


t- _g 


O units. 


O units. 


O units. 




•%° 


•§£ 


^i 


c. Corpuscle susp. 


c. Corpuscle susp. 


c. Corpuscle susp. 


1 




O =! 


2j 


(1 %), 1 c.c. 


(1 %), 1 c.c. 


(l^f). Ic.c. 


3 


:§s 


^i 


^ 


+ Antigen. 


4- Antigen. 


+ Antigen. 


C 


< 





Result 



Result 



Result 



In the original Wassermann reaction extract with physiological 
salt solution of a syphilitic liver was used as antigen. Later an 
alcoholic extract was used by Wassermann' s assistants. Still later 
Noguchi prepared a very much improved antigen by a method of 
evaporation, precipitation with acetone, and redissolving the product 
in ether. In this way he gets rid of many impurities and makes a 
fairly stable antigen. The Wassermann and the Noguchi tests differ 
in another and very important detail. In the Wassermann reaction 
the hemolytic system is based on sheep red blood-corpuscles, and a 
specific amboceptor for sheep corpuscles. The error of the method 
lies in the fact that human serum frequently contains a large amount 
of natural amboceptor for sheep red blood-corpuscles, which, together 
with the specific amboceptor that is later added, is often sufficient to 
cause hemolysis in those cases where there is little syphilitic ambocep- 
tor in the serum tested. To avoid this error Noguchi uses human red 



70 DISEASES OF CHILDREN. 

blood-corpuscles and a specific amboceptor for human red blood- 
corpuscles. The result is that the Noguchi method is noticeably more 
accurate than the original Wassermann. 

This test, the Wassermann or the Wassermann-Noguchi, can only 
be made in a well-equipped laboratory by men who have been especi- 
ally trained to do the work. It is doubtful if any man's work is reliable 
until he has completed two hundred tests. It therefore becomes 
important that the physician shall know how to obtain the considerable 
amount of blood necessary for the pathologist. 

Method of Collecting the Serum to be Tested. — Only about 2 c.c. 
of the patient's blood is needed. A convenient method is to puncture 




Fig. 17. 

the finger with a Hagedorn needle or a sharp-pointed scalpel. The 
blood can be driven toward the extremity of the finger by coiling 
around it tightly a small rubber tube or band. This may be repeated 
several times, allowing the hand to hang down previously to each 
winding for a few seconds. 

The blood is collected into a glass tube of rather large lumen, 
drawn out at either end into a capillary tube. During collection 
utilize both capillary attraction and gravity by holding the tube 
downward, or better still gentle suction can be made. After the 
blood is collected the two ends of the tube are sealed over a flame 
(alcohol lamp). 



SPECIAL EXAMINATIONS. 71 

Considerable blood may be collected by compressing a vein of the 
forearm and pricking it with a sharp needle. Another method is to 
push into a vein a small sterile aspirating needle, such as is used in 
blood culture work. Smal] bottles (2 to 4 c.c.) with a rubber or cork 
stopper and sealed with paraffin make convenient receptacles for the 
blood, if it is impossible to obtain the tubes already described. The 
first method described is simple, and yet it does seem to require 
practise to obtain a sufficient amount of blood for the test. On the 
other hand, almost anyone can fill a 2 to 4 c.c. bottle by pricking a 
vein or by making a small incision. 

The blood, if properly sealed, will keep for a number of days even 
at ordinary temperatures (four to five days at least). If kept in an 
ice-box, for even a longer time. 

Syphilis and the Wassermann Reaction. — The clinical aspects of 
the Wassermann reaction may be summed up as follows: 

1. The Wassermann-Noguchi test is more delicate than the origi- 
nal Wassermann test. 

2. The Wassermann and Wassermann-Noguchi test must be done 
by men especially trained for the work to obtain reliable results. 

3. A positive Wassermann or Wassermann-Noguchi is positive. 
The only other diseases which give a positive reaction are leprosy and 
yaws. 

4. A negative Wassermann does not necessarily mean that the 
patient is cured or has not a syphilitic infection. It is probable that 
a certain number of syphilitics give a negative reaction; this is 
especially true of those cases which are known as latent syphilis. 
Active syphilis is nearly always positive. 

5. The reaction does not become positive until just before the 
beginning of secondary symptoms. In hereditary syphilis those chil- 
dren born without symptoms as a rule give a negative reaction until 
just previous to the appearance of symptoms. If born with symp- 
toms the reaction is at once positive. 

6. Under treatment with mercury or iodides the reaction gener- 
ally becomes weaker and weaker, and finally disappears. The reac- 
tion may become positive again if treatment is stopped for a few days 
or weeks. In some cases, especially congenital syphilis, it is ex- 
tremely difficult to make the reaction disappear under treatment. 

7. Children born of syphilitic parents under treatment may or 
may not give a positive reaction. It is certain that a certain number 
of these children escape infection. 

8. Frequently the last child or children which manifest no symp- 



72 DISEASES OF CHILDREN. 

toms, though born of syphilitic parents, are negative to the Wasser- 
mann reaction. 

9. While the mothers of syphilitic infants may present no signs 
of syphilis, yet examination of the blood of the mothers gives a posi- 
tive reaction in half the number of cases examined. The negative 
reaction in the other half is due to the latency of the disease. 
Enough has been accomplished to throw doubt upon the dictum 
of Colles, and it can almost be said that the mother of a syphilitic 
child has syphilis. 



CHAPTER VIII. 
SIGNS OF ILLNESS IN INFANCY. 

As it is by no means easy in every case to tell exactly when or 
how an infant begins to be ill; a close observation of symptoms and 
their proper interpretation becomes highly important. Slight causes 
often produce very marked and sudden effects at this time of life. 
This is explained by the active growth of infants and especially by the 
rapid development and irritability of the nervous system. Thus a 
really slight indisposition may present the appearance of severe dis- 
ease, while the converse of this is sometimes true, as serious illness may 
so blunt this delicate nervous susceptibility as to cause the true 
gravity of certain cases to be overlooked. Attention may be called 
to various conditions that are evidences of some disturbance, and to 
note what they usually signify. 

Irritability of Temper. — In the absence of speech, the infant 
shows discomfort or suffering principally by cries and restlessness. If 
watched closely, it may by certain signs indicate to some extent the 
seat of the trouble. In headache, the hand will be frequently raised 
and held beside the head; in earache, the hand will be carried to the 
ear, and often pull upon that organ; in difficult and painful dentition, 
the fingers will be constantly inserted in the mouth, as if to pull out the 
cause of distress; irritation of the stomach and bowels may be accom- 
panied by a continual rubbing of the nose. During an attack of colic, 
the legs are drawn up over the abdomen, which feels hard, and there 
is likewise a writhing motion of the body. Crying is a very constant 
accompaniment of all kinds of illness. Constant, uninterrupted cry- 
ing is usually caused by earache, hunger, or thirst. If, after giving 
the baby suitable nourishment or a drink of water, it still keeps up 
a continuous, almost automatic cry, there is probably severe pain in 
the ear. This may be confirmed by pressing in front and behind this 
organ, when the baby will wince. Where there is some disease in the 
head, a sudden, piercing cry is uttered at certain intervals, between 
which there will probably be no fretting. In pneumonia, there is 
crying only during spells of coughing and a short time after; in pleurisy, 
there is likewise crjdng only during coughing, but it is shriller and 
shows more suffering than in pneumonia, and is also produced by mov- 

73 



74 DISEASES OF CHILDREN. 

ing the child and pressing over the affected side. Crying just before or 
after a movement of the bowels, with a twisting of the pelvis, gives 
evidence of intestinal pain. 

Where the hand is tightly shut, with the thumbs thrust deeply 
into the palms, and the toes strongly bent, there is much nervous 
irritation, which may eventuate in a convulsion. 

Restless Sleep. — Much may be learned by a careful inspection 
of an infant during sleep. A well child always sleeps quietly, but, 
when ill, sleep is fitful and sometimes only possible when the infant is 
rocked or patted or carried about in the arms. If there is a constant 
kicking off of the bedclothes, so that the child will not long keep covered 
even in cold weather, it is a pretty sure indication of rickets. When 
it is impossible for a child to sleep unless the head and shoulders are 
raised high upon a pillow, there is usually some disturbance in the ac- 
tion of the heart or lungs. If a child sleeps with its mouth wide open 
and the head thrown back, there is enlargement of the tonsils or ade- 
noid tissue at the vault of the pharynx interfering with natural quiet 
breathing through the nose. A persistent boring of the back of the 
head into the pillow points to cerebral irritation. When sleeping with 
half-open eyes, there is apt to be moderate pain present, and, if there 
is a constant movement of the lips, the discomfort is located in the 
gastrointestinal canal. 

Changes in the Features. — When illness is present, it is quickly 
shown in the countenance of the infant, which, during health, is in a 
condition of easy repose. In general, it can be stated that the upper 
part of the face is involved in diseases of the head, the middle part in 
affections of the chest, and the lower part in disturbances involving the 
abdominal organs. Thus in disease of the brain, the forehead and eye- 
brows will be sharply contracted, and the eyes sensitive to light with 
various changes in the pupils. Puffiness and swelhng about the eye-lids 
point to dropsy, which is usually caused by diseases of the kidneys 
following scarlet fever or other infectious process, but occasionally by 
severe anemia. In pneumonia and pleurisy the nostrils are sharply 
defined, and dilate and contract with the movements of respiration 
which will appear more or less labored. The mouth is the feature most 
affected in abdominal disease, shown by a drawing of the upper lip and 
other movements indicating pain. 

State of the Discharges. — A careful examination of all the 
organs opening upon the surface of the body must be made to detect 
any abnormal discharges. The ears, eyes, nose, mouth, urinary and 
rectal regions must thus be carefully inspected. 

The upright position of the stomach during infancy renders vomit- 



SIGNS OF ILLNESS IN INFANCY. /O 

ing a frequent and easy symptom when this organ is distended. In 
such a case there ma}' be a regurgitation of some sHghtly curdled milk 
after each feeding. The infant shows no distress from this act and con- 
tinues in a good condition of health; the stomach simply rejects 
any excess of food above that which it can readily hold. But sudden 
and profuse vomiting, without any error in diet, may constitute the 
beginning of severe illness, such as scarlet fever, diphtheria, or some 
brain disease. Acute illness in early life may begin with vomiting in 
place of the chill seen in older subjects. Vomiting may simply be a 
sign of local disturbance in the stomach, as when mucus is ejected in 
cases of gastric irritation. Where tough curds are vomited with the 
milk very sour, there is evidence of fermentation of the milk and an 
overacid condition of the stomach. If this persists, the mouth will 
become red and sore from a direct continuity of the irritation. 

Much can be learned by investigating the number and character 
of the discharges from the bowel. During the first two months there 
are usually three or four stools in the twenty-four hours, and during 
the first two years, two stools a day on an average. The stools are 
homogeneous, of a soft, semisolid consistency, and of yellowish color. 
In cases of diarrhea or inflammation they may be green, or contain 
hard, lumpy curds, or have an admixture of mucus and blood, or be 
of very watery consistency. Abnormal stools will be considered more 
at length in the section devoted to diarrhea. 

The urine is passed many times in the twenty-four hours, and the 
diaper ma}' have to be changed as often as every hour. Infants vary 
in this, however, as they ma}^ go six or eight hours without voiding 
urine. If twelve hours pass without it, a careful examination must 
be made in order to reveal the cause of retention. In some cases where 
the urine is highly acid, it may be expelled when a few drops collect 
in the bladder, and, as this amount quickly dries in the diaper, there 
is no'evidence from wetting that urine has been passed. A dark, smoke- 
colored urine may indicate nephritis, and thus be of great significance. 
Scant}^ urine, loaded with uric acid and the urates, may leave a red 
deposit upon the napkin simulating blood. 



CHAPTER IX. 
GENERAL THERAPEUTICS. 

Under this heading will be described methods and means of treat- 
ment that are ordinarily employed in pediatric practice. 

As these various m^easures are used in a number of conditions, it 
is advisable to discuss them at some length and later refer to this 
chapter when outlining the treatment for a certain disease. 

Drug Administration. 

Never prescribe a drug without a good and sufficient reason. 
Prescribe so that the dose will be small in amount and as agreeable as 
possible. Heavy syrupy mixtures may be agreeable, but are apt to 
give rise to fermentation from excess of sugar. Pills and capsules 
are not intended for children who rarely can swallow them. Pre- 
scriptions should be simple and if possible contain but one or at most 
two drugs. Powders made up with sugar of milk are mixed with water 
and given from the teaspoon. Tablet triturates form an easy and 
accurate method of giving drugs (except nitroglycerin). If the child 
is unwilling, the medication on the spoon is quickly slipped on to the 
tongue and the spoon held in position well back until swallowing takes 
place. . In this way the child cannot regurgitate it. 

Begin with small doses in early life and increase if the desired effect 
is not obtained. Heroic doses, however, may be used in emergencies 
where rapid and active stimulation is required. Hypodermatic in- 
jection of the stimulant is often required to produce physiological 
effects. 

The rule that an infant up to a year should receive one-twentieth 
of, and at one year one-tenth of the adult dose, is to be followed in the 
majority of cases. The stimulants, however, are exceptions to this 
rule. At the fifth year one-fifth, and about the tenth year one-half 
the adult dosage is usually to be given. 

Castor oil should be administered ice cold on a wet spoon. The 
taste of quinine in solution may be disguised with syrup of yerba santa, 
extract of licorice or syrup of wild. cherry, but it is not unusual to find 
children who take bitter medication better than adults. Tasteless 
quinin in the form of euquinin, tannate of quinin, or saccharated 

76 



GENERAL THERAPEUTICS. 



77 



quinin is now obtainable. Sweet chocolate disguises the taste ad- 
mirably. Opium or its derivates, with the exception of codein, are 
to be largely avoided. The coal-tar derivatives, combined with caffein 
are used at times to control pain. They should be given in small 
doses, and not as a routine measure for the control of pyrexia. 

The drugs or preparations of drugs most frequently used internally 
with the greatest advantage in pediatric practice are: 



(1) 
Calomel. 
Castor oil. 
Fowler's solution, 
Basham's mixture. 
Bismuth subnitrate. 
Bromids. 
Cascara sagrada. 
Cod-liver oil. 
Strychnin sulphate. 
Digitalis. 

Sweet spirits of niter. 
Syrup of iodid of iron. 
Tincture of nux vomica. 
Salicylates. 
Alcohol. 

Potassium iodid. 
Ammonium compounds. 



(2) . 
Atropin. 
Camphor. 
Nitroglycerin. 
Chloral hydrate. 
Codein phosphate. 
Dover's powder. 
Hexamethylenamin. 
Hydrochloric acid. 
Liquorice powder. 
Phenacetin. 
Rhubarb. 
Salol. 

Iron compounds. 
Asafetida. 
Santonin. 
Aspidium. 
Ipecac. 



TABLE OF AVERAGE DOSAGE. 



Drus: 




Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 



Aconite Tinct. (10 per cent.) gtt. ^ 

Ammonium Chloride i gr. ^ 

Ammonium Carbonate . . . . { gr. j 
Ammonium Acetate Sol. 

(Spirit Mindererus) 

Ammonium Aromatic Spts. 

(Liq. Ammonii Anisatis) . 

Antipyrin 

Antitoxin. 
Diphtheritic 

Immunization 



Pharyngeal Type 
Laryngeal Type . , 



Arsenic 

Fowler's Sol. (Liq. Pot. 
Arsenitis) 



Arsenious Acid gr 



gtt. 10 
gtt. 3 
gtt. 1-2 
gr. i 



500 units 



gtt. i 
gr. h 
gr. i 

dr. 1 

gtt. 5 
gtt. 3 
gr. 1 



500 to 
1,000 units 



3,000 units 5,000 units 



10,000 
units 



n i 



10,000 
units 



ni 



gr. 3^0 



gtt. 1-2 
gr. 1-2 
gr. 1-2 

dr. 1-2 
gtt. 10 
gtt. 5 
gr. 2-3 



500 to 
1,000 units 

5,000 units 
10,000 
units 



n 2-3 



gr. 



q. 2-4 hrs 
q. 2-4 hrs. 
q. 2-4 hrs. 

q. 4 hrs. 
q. 1-4 hrs. 
q. 1-4 hrs. 
t.i.d. 



Repeat 
or double 
the dose 
in 12 hrs. 
if neces- 
sary. 



t.i.d. 
t.i.d. 



"I 

gr. 

gr. 



2-6 

12-24 

12-24 



dr. 3-6 
dr. i-li 
gtt.30-dr.l 
gr. 5-10 



to effect 



vf[ 10, or 
to effect 
gr. -sio~TE 



78 



DISEASES OF CHILDREN. 
TABLE OF AVERAGE DOSAGE.— Continued. 



Drug 



Dose, 

Age 

6 mos. 



Dose, 

Age 

2 yrs. 



Dose, 

Age 

3 to 5 yrs. 



Dose, 
Frequency 



Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 



Asafetida, Milk of, by 
rectum only 

Aspidium Oleoresin 

Aspirin 

Atropin 

Basham's Mixture 

Belladonna Tinct 

Beta-naphthol 

Benzoic Acid 

Bismuth Subcarbonate . . . 

Bismuth Subgallate 

(Dermatol) 

Bismuth Subnitrate 

Bismuth Salicylate 

Brandy (Cognac) 

Bromide, Ammonium 1 

Bromide, Potassium i 

Bromide, Sodium ] ' ' ' 

Bromide, Strontium J 

Brown Mixture (see Lico- 
rice Comp. Mixt.). 

Caffein Citrate 

Calcium Chlorid 

Calcium Sulphid 

Calomel 



dr. 1 



gr. 1 



Camphor, Pulverized 

Camphor Spts. 10 per cent, 
Cascara Sagrada, Ext . . . . 
Cascara Sagrada, Fluid Ext, 

Castor Oil 

Cerium Oxalate 

Chalk, Prepared 

Chalk Compound Mixt 

Chloral Hydrate . . 

Chloroform Spirits 

Cinchona (see Quinin). 

Codein 

Cod-Hver Oil 

Creosote 

Creosote Carbonate 

Digitalis, Tinct 

Digitalis, Infusion 

Digitalin 

Dover's Powders (see 

Opium Powders of 

Ipecac). 

Dionin 

Ergot, Fluid Extract 

Ether, Compound Spts. 

(Hoffman's Anodyne) . . . 
Ether, Nitrous Spts. of 

(Sweet Spirits of Niter) . . 



gtt.i 
gr. i 
gr. 1. 
gr. 5 



gr. 2-3 
gr. 5-10 
gr. i-1 
gtt. 5-10 

gr. 1-3 



gr. i-i 
gr. i 
gr. -io 
gr. To-1 



gr. i\ 



dr. 1 



gr. 2 
dr. 1 
gr. i 
gtt. 1-2 

gr. TO 
dr. 1 



gtt.i 
gtt. 10 
gr. 3^ 



gr. -io 
gtt. 2-3 

gtt. 2 

gtt. 2 



dr. 1-2 
\r[ 10 
gr. 1-2 
gr ^h 
dr. i 
gtt. 1 
gr. i 
gr. 2 
gr. 10-15 

gr. 5-10 
gr. 10-15 
gr. 1-2 



dr. 1-2 

TT]^ 30 

gr. 3-5 
gr. ^h 
dr. 1 
gtt. 2-5 
gr. 1 
gr. 3-5 
gr. 15-30 

gr. 5-10 
gr. 10-30 
gr. 2-3 



gtt. 10-20 gtt. 20-30 



gr. 3-5 



gr. i-i 
gr. 1 

gr. io 
gr. i-1 

gr. i 
gtt. 5 
gr. -I 
gtt. 5 
dr. 1-2 
gr. 1-2 
gr. 3 
dr. 1 
gr. 1-2 
gtt. 2-3 

gr. 2V 
dr. i 
gtt. 1-2 
gtt. 1-2 
gtt. 1-2 
dr. i 
gr. ih 



gr. 2% 
gtt. 5 

gtt. 5 

stt. 5 



gr. 5-8 



gr. i 
gr. 2 

gr. TO 
gr. i-2 

gr. i 
gtt. 5-10 
gr. 1-2 
gtt. 5-10 
dr. 1-4 
gr. 2-3 
gr. 5-8 
dr. 1-2 
gr. 2-3 
gtt. 5-10 

gr. tV 
dr. 1-2 
gtt. 2-3 
gtt. 2-3 
gtt. 2-3 
dr. 1-3 
gr. jh 



gr. tV 
gtt. 10-15 

gtt. 10 

gtt. 10 



pro doso 

once 
q. 4 hrs. 
q. 4 hrs. 
t.i.d. 
q. 4 hrs. 
t.i.d. 
q. 4 hrs. 
p.r.n. 

p.r.n. 
p.r.n. 
p.r.n. 
q. 3 hrs. 

q. 4 hrs. 



q. 4 hrs. 

t.i.d. 

t.i.d. 
in divided 

doses 
q.2 to 4 hrs. 

t.i.d. 

t.i.d. 

t.i.d. 

pro doso 

t.i.d. 

q. 4 hrs. 

q. 3 hrs. 

q. 4 hrs. 

q. 4 hrs. 

q.4 hrs. 
t.i.d. 
t.i.d. 
t.i.d. 
q. 4 hrs. 
t.i.d. 
p.r.n. 



t.i.d. 
t.i.d. 

p.r.n. 

q. 1-2 hrs, 



dr. 2 
ni 10-30 
gr. 15-20 
gr. io 
oz. i 
T.^ 5-10 
gr. 3 
gr. 5-10 
dr. 2-3 

dr. 21 
oz. i 
gr. 5-15 
dr. 1-oz. I 

gr. 25-40 



gr. 2 
gr. 4-6 
gr. tV4 
gr. i-2 

gr. i-1 
nt 10-30 
gr. 2-5 
dr. i 
oz. i 
gr. 5-10 
gr. 20^30 
oz. 1 
gr. 5-10 
dr. 4 

gr. i-l 
oz. i-1 
gtt. 5-10 
gtt. 5-10 
gtt. 5-15 
dr. 3-oz. 1 
gr. 5V 



dr. i 
dr. i 
dr. li 



GENERAL THERAPEUTICS. 
TABLE OF AVERAGE DOSAGE.— Continued. 



79 



Drug 


Dose, 

Age 

6 mos. 


Dose, 
Age 

2 yrs. 


Dose, 

Age 

3 to 5 yrs. 


Dose, 
Frequency 


Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 


Ferric Prep, (see Iron). 
Fluoroform (2.8 per cent, 
sol.) 


gtt. 1 


gtt. 2 

gr. 30 

gr. 3*7 

gtt. J 
gr.l 
gr. i-u 

gr.l 

gtt. 2 
gtt. 2 

gr.2 

gr.2 

gr.l 

gtt. 5 

nx 5 
gr. i 
TTl 10 

dr. 1 

gtt. 3 
gr.2 

gtt. 20-30 

gr. 20 

dr.i 

oz. 2 
gr. 30 

gr. xk 


gtt. 6 

dr. 1 

gr. 2*0 
to iJo 
gtt. 1 
gr. 5 
gr. iV 

gr. 2-5 

gtt. 5 
gtt. 3 

gr.3 

gr. 5 

n 3 

gr.3 
gtt. 5-10 

nx 15 
gr. 1 
ni 30 
dr. i-1 

gtt. 5 
gr.3 

gtt. 30-40 

gr.40-dr.l 

dr. 1 

oz. 4 
gr. 60 

gr. sV 


q. 2 hrs. 

pro doso 
q. 2-4 hrs. 

q. 2-4 hrs. 
q. 4 hrs. 
q. 4 hrs. 

t.i.d. 

t.i.d. 
t.i.d. 

t.i.d. 

t.i.d. 
t.i.d. 

t.i.d. 
t.i.d. 

^i.d. 
t.i.d. 
t.i.d. 
q. h hrs. 
to effect 

q 4 hrs. 
once 

q. 3 hrs. 

bed time 

t.i.d. 

in A. M. 

in A. M. 

t.i.d. 


gtt. 48 
dr. 1-3 


Fowler's Sol. (see Arsenic 

Liq. Potass.). 
Glauber's Salts 


Glonoin (Nitroglycerin). .. 

Glonoin (Spts. of) 

Guaiacol Carbonate 

Heroin Hydrochlorid 

Hexamethylenamin (Uro- 
tropin) 


gtt. i 
gr.i 
gr. T^ 

gr.i 

gtt. i 
gtt. i 

gr. 1 

gr. 1 

gr.i 


gr. 3'o-2V 

gtt. 4-8 
gr. 20 
gr. tV 

gr. 5—15 


Hoffmann's Anodyne (see 
Ether Spts. Comp.). 

Hydrochloric Acid, Dilute 

Hyoscyamus Tinct 

Hydrargyrum (see Mercury). 

lodid, Sodium, and Potas- 
sium 


gtt. 15- 
gtt. 10 

gr, 5-10 


Iron. 
Iron, Oxid Saccharated . . . 

Ferric Chlorid, Tine 

Liq. Ferri et Ammonium 

Acetatis (see Basham's 

Mixt.). 
Soluble Citrate of Iron 

(Ferri et Ammonii Citras) 
Syrup of lodid of Iron 


gr. 3-15 

gr. 3-10 

gtt. 15- 

dr. i 

TTL 45 
gr. 3 
dr. li 
dr. 3 

dr. * 


Pyrophosphate of Iron, 
(Soluble) EHxir of 




Reduced Iron . . ... 




Liq. Ferri Peptonati (N.F.) . 
Ipecac, Wine of (Emesis) . . 

Ipecac, Syrup of (Expector- 
ant) .... 


nx 5 

gtt. 5 

gtt. 2 
gr. J 

gtt. 15 

gr. 10 

oz. i 
gr. 15 

gr- ih 


Jalap, Powdered ... . 


gr.3 

dr. 2-oz. 1 
dr. J-1 
dr. 3 


Licorice Compound Mixt. 

(Brown Mixture) 

Liquorice Compound Pow- 


Masma Magnesia (N. F.) 
Milk of Mag 


Magnesium Citrate 

(Liq. Magnesia Citrate 
Effervescent) 


oz. 6 


Magnesium Sulphate 

Male Fern, Oleoresin (see 

Aspidium). 
Mercury Bichlorid 


dr. 1 
gr. 15 



80 



DISEASES OF CHILDREN. 
TABLE OF AVERAGE DOS AGE. —Continued. 



Drug 



Dose, 

Age 

6 mos. 



Dose, 
Age 

2 yrs. 



Dose, 

Age 

3 to 5 yrs. 



Dose, 
Frequency 



Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 



Mercury Mild 
(Calomel) . . . . 



Chlorid 



Mercury Biniodid 

Mercury with Chalk (Gray 

Powder) 

Morphin Sulphate 

Niter, Sweet Spirits of (see 

Ether Spts. Nitrous). 
Nitroglycerin (see Glonoin) 

Nux Vomica Tinct 

Novaspirin 

Opium Tinct. (Laudanum) 
Opium, Camphorated Tinct. 
Opium, Power of Ipecac and 

(Dover's Powder) .... 
Peppermint Water (Aqua 

Mentha Piperita) 

Pepsin Powdered 

Pepsin Essence of (N. F.) . . 
Phenacetin (Acetpheneti- 

din) 

Phosphorus 

Syr. Calcii Lactophos. , . 

Phosphoric Acid Dil. . . . , 

Syr. Hypophosphites . . , 

Potassium Acetate , 

Potassium Bitartrate ..... 

Potassium Bromid , 

Potassium Citrate , 

Potassium Chlorate , 

Potassium lodid (Expec- 
torant) 

Potassium lodid (as Anti 

syphilitic) , 

Quinin, Sulphate and Bi- 

sulphate 

Rhubarb Powdered .... 
Rhubarb Syrup Arom. . . 
Rhubarb and Soda Mixture 
Rhubarb and Anisated 

Magnesia Pulv. (N. F.) . . 

Salicin 

Sodium Salicylate 

Methyl Salicylate 

Aspirin 

Oil of Wintergreen 

Salol 

Santonin 

Serum Antidiphtheritic (see 

Antitoxin). 
Serum Antimeningitic . . 



gr. i 



gtt. 1 
gr. 1 



gtt. 3-5 
gr.i-i 

dr. i 
gr. 1 
gtt. 20 

gr. i 

gtt. 10 
gtt. 1-2 
gtt. 15 
gr. 1 
dr. i 
gr. 1-3 
gr. 1 
gr. i 

gr. i 

gr. 1 

gr. i 
gr. 1 
gtt. 15 



gr. 3 



gr. 1 
gtt. 1 
gr. i 



15 C.C. 



Sodium Benzoate ^. 1 



gr. i-1 

gr. ^ 

gr. i 
gr. ^ 



gtt. 2 
gr. 1-2 
gtt. 1-2 
gtt. 15 

gr. f 

dr. 2 
gr. 2 
gtt. 30 

gr. 1 

gtt. 30 
gtt. 5 
gtt. 30 
gr. 3 
dr. 2 
gr. 3-5 
gr. 2 
gr. 2 

gr. i 
gr. 2 

gr. 1-2 

gr. 3 
dr. 1-2 

dr. J-1 

gr. 5-10 
gr. 1-2 
gr. 2 
gtt. 3 
gr. 1-2 
gtt. 3 
gr. 1-2 
gr. i 



15 C.C. 

gr. 2 



gr.i-2 
gr. -h 

gr. i-1 
gr. 23 



gtt. 3-6 
gr. 3-5 
gtt. 2-3 
gtt. 20 

gr. 1-2 

dr. 4 
gr. 3 
dr. 1 

gr. 2 

dr. 1 

gtt. 10 
dr. i-1 
gr. 5 
dr. 4 
gr. 5-8 
gr. 5 
gr. 3 

gr. 1 

gr. 3 

gr. 2-3 

gr. 5 
dr. 1-2 

dr. 1-2 

gr. 10-20 
gr. 2-3 
gr. 3-5 
gtt.. 5 
gr. 3-5 
gtt. 5 
gr. 2-3 
gr. i 



30 c.c. 

gr.3 



in divided 
doses 
ti.d. 

t.i.d. 
p.r.n. 



t.i.d. 

q. 4 hrs. 
p.r.n. 
q. 4 hrs. 

p.r.n. 

t.i.d, 
t.i.d. 
t.i.d. 

q. 4 hrs. 

t.i.d. 
t.i.d. 
t.i.d. 
t.i.d. 
once 
q. 4 hrs. 
q. 4 hrs. 
t.i.d. 

q. 2-4 hrs. 

t.i.d. 

q. 4 hrs. 
t.i.d. 
t.i.d. 
t.i.d. 

b.i.d. 
q. 3 hrs. 
q. 3 hrs. 
q. 2-3 hrs. 
q. 4 hrs. 
q. 2-3 hrs. 
t.i.d. 
q. 4 hrs. 



daily for 4 

days 

q. 4 hrs. 



gr. i-2 

gr. I -' 

gr. 3 
gr. tV 



gtt. 5-15 
gr. 15-20 
gtt. 10 
dr. 1-2 

gr. 1-5 

oz. 1-1| 
gr. 5-10 
dr. 3 

gr. 4-8 

dr. 3 
dr. i 
dr. 3 
gr. 15 
oz. ^ 
gr. 25-40 
gr. 15-30 
gr. 10 

gr. 10 

gr. 10 

gr. 5-15 
gr. 15 
oz. I 
oz. i 

gr. 40 
gr. 24 
dr. 1 
IT] 20-30 
gr. 15-20 
gtt. 30 
gr. 10 
gr. 1-2 



pro doso 

gr. 10-15 



GENERAL THERAPEUTICS. 
TABLE OF AVERAGE B OS AGF..— Continued. 



81 



Drug 



Dose, 

Age 

6 mos. 



Dose, 
Age 

2 yrs. 



Dose, 

Age 

3 to 5 yrs 



Dose, 
Frequency 



Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 



Sodium Bicarbonate 
Sodium Bromid. . . . 

Sodium lodid 

Sodium Phosphate . 
Sodium Sulphate . . 
Spartein Sulphate . 
Strophanthus Tinct . 
Strychnin Sulphate 

Tanalbin 

Tannigen 

Tartar Emetic .... 
Terpin Hydrate 
Thyroid JExt. Desic, 

Thymol , 

Urotropin 

Veronal 

Whisky 



gr. 2 
gr. 1-3 
gr. 1 
gr. 15 



gr. 31) 
gtt. 1 

gr. jh 

gr. 1 

gr. 1 

gr. 270- 



gr. i-1 
gr. i 
gtt. 10 



gr. 3 
gr. 3-5 
gr. 2 
gr. 30 
gr. 30 

gr. tVto 
gtt. 2 

gr- YTTO TTO 

gr. 3 
gr. 3 
gr. xio 
gr. i 
gr. 1-2 
gr. 1-2 
gr. 1 
gr. 1 
gtt. 10-20 



gr. 5-10 
gr. 5-8 
gr. 3 
gr. 60 
gr. 60 

gr-rV-i 
gtt. 3 

gr. T^o 
gr. 5 
gr. 5 
gr. Th 
gr. i 
gr. 3 
gr. 2-5 
gr. 2-5 
gr. 1-2 
gtt. 30-40 



p.r.n. 
q. 4 hrs. 
t.i.d. 
pro doso 
pro doso 



hrs. 
hrs. 
hrs. 
hrs. 
hrs. 
hrs. 



q- 
q- 
q- 
q- 
q- 

q. 3-4 hrs. 
t.i.d. 
t.i.d. 
t.i.d. 
once 
q. 4 hrs. 
or oftener 



gr. 20-30 
gr. 25-40 
gr. 5-10 
dr. 1 
dr. 1-3 
gr. I 
gtt. 12 

gr. ij 
dr. 1 
dr. 1 
gr. ijV 
gr. 3 
gr. 9 
gr. 15 
gr. 5-15 
gr. 2 
oz. J 



Introductory Remarks. 

The treatment of diseases in children requires a thorough knowl- 
edge of all measures, besides drugs, that may be used for alleviation 
or cure. If the medical attendant places sufficient dependence upon 
such measures as hydrotherapy, fresh air, and diet he will be inclined 
to order fewer drugs or only such as are still indicated. Familiarity 
with the details of the general therapeutics of childhood will make 
him resourceful and capable of adapting his treatment to the particular 
surroundings and needs of the child. 

The physician should take into consideration the general develop- 
mental condition of the child, its usual habits and the intelligence 
of those who will carry out his orders. Orders should always be spe- 
cific, and are preferably written out in detail, as a mother's anxiety 
for her sick child may lead to misunderstandings which may prove 
serious. 

While many of the diseases are self-limited, and recoveries are 
generally speedy because of the recuperative powers in early life, 
still the practitioner should always alleviate distress and hasten 
complete recovery by the proper use of drugs and other medical 
measures. 

Prescriptions should be simple, containing only one or two in- 
6- 



82 DISEASES OF CHILDREN. 

gredientS; and made as palatable as possible without endangering the 
child's digestion. Glycerin or saccharin well serve this purpose 
and are to be preferred to the syrups or sweet elixirs which so readily 
cause fermentation. Medication and other measures for relief should 
be so arranged that the child will not be continually disturbed; for 
rest is an important adjunct in all cases. 

In the practice of pediatrics preventive treatment should be 
considered first, last, and all the time, for it is only thus, through 
the saving of lives and the rearing of healthy children who can later 
become* healthy parentS; that infant mortality can really be reduced. 

Psychotherapy. 

The influence that can be exerted for good or evil, over the recep- 
civemind of a child has been well emphasized in recent years by psy- 
thologists and physicians. Often a good part of a physician's success 
in handling little patients is due to his knowledge and interest in their 
mental processes. He learns to take advantage of their susceptibility 
to conviction, to suggestion, or of their pride, and control is thus easily 
acquired. The harmful influence of certain members of the family 
may prevent good results, especially in neurotic diseases, until the child 
is removed to different surroundings. A stranger often has better 
control over the sick child than its own mother. Time spent in study- 
ing the mental attributes of a seemingly incorrigible patient is well 
spent, for almost without exception the maturer mind conquers by per- 
sistence tempered with kind indifference. 

In older children hysterical manifestations can be controlled by 
the forceful attendant and their repetition prevented by a radical 
change in environment and daily routine. Such conditions as enuresis 
we have often been able to cure by psychic influences depending 
mainly upon the child's pride. Another factor often lost sight of in 
this connection is the influence of associates. , Through a proper 
selection of playmates in age and temperament, much may be done 
from a psychic standpoint. 

Aero therapy. 

It is a deplorable fact that there is any need of emphazing the 
use of fresh air in the treatment of disease. The laity, however, have 
been so imbued for years with the idea that colds are the result of cold 
air, and that sickness in the house demands warm rooms that the 
practitioner, in spite of his better judgment, often acquiesces in these 
notions. Among the more intelligent of our population the need of 



GENERAL THERAPEUTICS. 



83 




Fig. 18. — Aerotherapy in the tenements — improvised portable 
bed from bath-tub. 



84 DISEASES OF CHILDREN. 

an outdoor life is beginning to be appreciated, and it only demands that 
orders for sufficient fresli air be given with a spirit of conviction that 
the method is a right and just one, to gain the cooperation of the 
parents. The harmful influence of impure air or a paucity of fresh 
air is no better illustrated than by comparing the poor results formerly 
obtained in institutions and hospitals for children, even when skillful 
nursing was at hand, to the good results obtained with abundance of 
fresh air. 

Aerotherapy, or an abundance of pure fresh air, should be ar- 
ranged for in every sick-room as well as in the nurseries of healthy chil- 
dren. In respiratory diseases accompanied with fever the good 
effects of cool fresh air are particularly noticeable. 

In convalescence a change to the country or seaside, where ozone 
is abundant, will do more than a course of iron tonics or artificial stimu- 
lants. The summer diarrheas are often promptly alleviated by a so- 
journ in a cool and dry atmosphere. 

Hydrotheraphy. 

The use of water is safer and often more effective than the use 
of antipyretics in reducing temperature. It also has a tonic effect 
instead of the depressing effect of antipyretic drugs. A warm bath 
given to a child conserves the body heat, is sedative in its action, and 
increases the perspiration. On the other hand, cold baths decrease 
the body heat and leave a stimulating and eliminative action. 

Sponge Baths. — Cool sponge baths with or without alcohol are 
effectual and usually agreeable to children when their temperature is 
high. Cold baths or cold packs are rarely necessary and may be pro- 
ductive of considerable shock. Equal parts of alcohol and water at 
90° F. are applied to the child lying in a woolen blanket; gentle friction 
causes air evaporation and reduction of temperature. While the bath 
is in progress ice cold cloths may be placed on the forehead and head of 
the child. 

Sheet or Bed Baths. — Rubber sheeting is spread on the bed and a 
soft sheet or blanket is wrung out of water at 90° to 100° F. The 
patient is wrapped in this and cold applications at 60° F. placed to the 
head. In older children water at a lower temperature 70° or 80° F. 
may be sprinkled over the sheet to effect a further reduction of body 
heat. The patient should remain in such a bath for about twenty 
minutes and it may be repeated several times during the day if the 
necessity arises. 

Ice Cap. — For persistent high temperature with delirium an ice 
cap may be placed at the nape of the neck or on top of the occiput. 



GENERAL THERAPEUTICS. 85 

The thin rubber ice bladders are half filled with small pieces of cracked 
ice and all air is expelled. They should be used only intermittently, 
and a trained attendant should be present as all cases do not respond 
well to its application. 

Ice Poultice. — Small pieces of cracked ice are mixed with an 
equal portion of bran or sawdust and WTapped in oil silk or rubber 
sheeting in such a way as to prevent leaking. This may be used as the 
ice cap above, but has the advantage that it may be improvised at 
home. 

Compresses — Compresses wrung out of water varying from 
80° to 100° F. according to indications may be applied to the neck in 
tonsilitis, over the abdomen for enteralgia and about the chest in cases 
of pneumonia. When used on the chest they should be divided into 
two portions, one for the left and one for the right, so that they may 
be removed with as little disturbance as possible to the patient. 
They may also be applied to the exposed part of the chest in one piece 
and tucked around as far as possible without disturbing the child. 

Warm and hot baths are agreeable, soothing, and sedative. The 
temperature of the body is reduced and the relaxation which follows 
promotes sleep. Diuresis is also promoted. A warm bath is given at 
a temperature of 85° to 98° F., while a hot bath may range to 110° F. 
The warm bath is suitable for the reduction of temperature, and should 
last from five to fifteen minutes. Cool applications may be placed 
upon the head if the pyrexia is particularly high. Hot baths should 
be given to asthenic infants when the temperature is high or sub- 
normal. The addition of mustard is useful, especially if there are evi- 
dences of shock or collapse. The baths should be short, not exceeding 
over five minutes in duration. The patient should be wrapped in 
warmed woolen blankets and allowed to rest, unless free perspiration 
is indicated as in nephritis, when hot drinks -may also be given. 

A hot pack is useful in nephritic or uremic cases. The child is 
wrapped in a woolen blanket wrung out of water at 110° F. and covered 
with another dry one, beneath which are placed numerous hot-water 
bags. Hot drinks are offered. The pulse should be watched and the 
child removed when a free perspiration is induced. 

A hot-air bath is given by introducing hot air from a croup kettle 
under the blankets of the bed for about half an hour or until free 
diaphoresis is obtained. 

Special Baths. 

A brine bath is given by adding a half-pound of sea salt to six 
gallons of water at a temperature of 105° F. and gradually reducing to 



ob DISEASES OF CHILDREN, 

90° F, Gentle friction should be kept up throughout the bath which 
should not last longer than fifteen minutes. It is indicated as a 
stimulating bath for undernourished, poorly developed children, es- 
pecially those with scrofulous tendencies. 

The addition of bran, starch or bicarbonate of soda in luke-warm 
water will serve to allay the irritation of certain skin diseases, as urti- 




Fig. 19. — Method of giving hot dry pack. 



caria. A quarter of a pound of soda is sufficient for a six-gallon bath. 
When a bran bath is given half a pint of bran in a cheesecloth bag is 
drawn through the water. For the starch bath a quarter of a pound, 
or half a cup, of raw starch is slowly dissolved in the water. 

A soothing bath which will promote sleep in nervous, irritable 
children is made by the addition of fifteen drops of pine-needle oil to 
the water at 110° F. No friction should be made. 

A mustard bath is prepared by immersing an ounce of mustard in 
a cheese cloth or muslin bag in the water usually at a temperature of 



GENERAL THERAPEUTICSo 87 

105° F. Cold compresses are applied to the head, and the body is 
gently rubbed. 

Carbonic acid baths (artificial Nauheim baths) may be prepared 
by the addition of chemicals or specially prepared Triton salts to the 
water, but the evolution of the gas is somewhat uncertain and irregular. 
The gas may be generated by the action of bicarbonate of soda and 
hydrochloric acid in a porcelain-lined tub. The acid being diffused 
through the water after the soda has been dissolved. Another 
method has recently been placed on the market which is dependent 
upon the use of a specially constructed mat through which the gas is 
allowed to flow from a cylinder of the compressed 
gas. The flow of gas is greater, it is more evenly 
distributed through the bath and it can be regulated. 
It is certainly preferable to the older methods for 
home use (Fig. 20). The bath is given at 90° to 95° 




Fig. 20. — Carbonic acid gas bath, with seat, tank, and manometer for home use. 



F. for five minutes and is followed by gentle friction and rest in bed 
for several hours.. These baths must be given at least three times a 
week for several months to produce permanently good effects. The 
baths are indicated in the convalescent stages of myocardial diseases. 

The Nasopharyngeal Toilet 

The nasopharyngeal toilet, as advocated by Caille, is a valuable 
prophylactic measure in diseases affecting or emanating from the res- 
piratory tract, and is an effective adjunct in promoting a healthy 
condition of the nasopharyngeal mucous membrane in many febrile 
diseases. 

Method. — The method consists in slowly pouring into each nostril, 
by means of an ordinary teaspoon, a drachm of normal salt solution 
while the child lies with his head tilted back over a pillow and his 
mouth open. If gentleness is combined with tact when the measure 



88 DISEASES OF CHILDREN. 

is first attempted, the child soon learns that the method is not painful 
nor disagreeable. It can be used to advantage in such infectious dis- 
eases as diphtheria and scarlatina, and before and after operations upon 
the nose and throat, as in adenectomy and tonsillotomy and retro- 
pharyngeal abscess. 

Lavage. 

{Stomach Washing.) 

This is a useful practice, but one which is often much abused. 
It is indicated as an initial procedure for persistent vomiting, especially 
in summer diarrhea, in cases of chronic gastrointestinal indigestion, 
acute gastritis, poisoning, in persistent vomiting, and preceding certain 
operative procedures as intestinal obstruction. Repeated stomach 
washing is to be deprecated. If the symptoms persist it is usually an 
indication that the dietary regulation is faulty. 

The apparatus used is made with a soft-rubber catheter. No. 12 
American, attached by means of a piece of glass tubing to another length 
of rubber tubing at the end of which is placed a small funnel. The 
catheter is introduced into the esophagus without any difficulty and 
with little discomfort to the infant. A warmed fluid which may be 
either a normal saline solution, or contain bicarbonate of soda (a 
dram to the pint) or boric acid 2 per cent, is used in amounts depend- 
ing upon the age and development of the child (see Chap. V). When 
the stomach is full this will be noted in the funnel, which is then 
depressed and the contents siphoned off. This process is repeated 
until the return flow is clear. The preferable method is to hold the 
child upright in the nurse's lap, the head being slightly inclined for- 
ward; if for any reason this is contraindicated the infant may be 
placed on its side, but this position requires more dexterity than the 
upright. 

Enteroclysis. 

Enterocylsis is a measure which can readily be used in infants and 
children. No special apparatus is required as in venous infusions or 
hypodermoclyois. In the latter, surgical cleanliness must be. strictly 
observed, and it is difficult to carry out the technic, without trained 
assistants, outside of a hospital. Flushing the colon not only clears 
out the lower intestinal tract of deleterious material, but it stimulates 
renal secretion, thus promoting the excretion of toxic products. If 
there is high temperature this will be reduced and thirst assuaged. 
The absorption of the fluid increases the blood pressure, and by elimi- 



GENERAL THERAPEUTICS. 



89 



nating poisonous products indirectly assists in renewing the condition 
of the blood itself. 

Method. — A soft-rubber rectal tube is attached to the end of a 
fountain bag into which has been poured a saline solution made by 
dissolving two teaspoonfuls of salt to two quarts of water at 110° F. 
The bag should be hung about three feet above the patient and the 
water allowed to flow slowly into the gut. If the intestine is irritable 




Fig. 21. — Apparatus for hypodermoclysis. 



the pressure may be lowered so that the water will flow very slowly 
after the bowel has been emptied. Fluids will not penetrate beyond 
the ileocecal valve, but the entire intestinal tract will be stimulated to 
greater activity by the process. 

In place of the saline solution it is often of advantage to use a 
bland soothing preparation, such as starch water, or, on the contrary, 
soap suds may be necessary if the intestine is inactive. 

The indications for flushing or irrigation of the bowel are the 
removal of the putrescent material, as in enteritis and cholera infan- 
tum, and to assist elimination in the infectious disease, such as 



tu DISEASES OF CHILDREN. 

typhoid and scarlet fever. It is also of distinct value in septic condi- 
tions and nephritis. In conjunction with baths it may also be used 
to reduce high temperatures, thus counteracting the harmful effects 
produced by the loss of fluids in the tissues. Once a day is usually 
sufficient. The mucous membrane is rendered irritable by too frequent 
irrigations. 




Fig. 22, — Enteroclysis: position of the patient for bowel irrigation. 

Gavage. 

Gavage, or forced feeding by the stomach-tube, is accomplished 
with the same kind of apparatus as that used for enteroclysis, that is, 
a No. 12 American, soft-rubber catheter, a piece of tubing and an eight- 
ounce funnel, preferably of glass. The upright or the prone position, 
with the child lying on its back, may be selected. With infants no 
mouth-gag is required. In older children a mouth-gag, well protected 
*by pieces of rubber to prevent laceration of the gums, will be necessary. 
Before introducing the food for the first time it is better to do a prelimi- 
nary stomach washing. The food is allowed to flow slowly into the 
stomach, and when the desired amount has been introduced the 



GENERAL THERAPEUTICS. 



91 



catheter should be quickly withdrawn, the tube first being firmly 
pinched to prevent regurgitation and the entrance of any of its 
contents into the larynx. The infant should then be placed in bed 
and not disturbed, as in highly irritable conditions the food might 
be regurgitated. 




Fig. 23, — Position and apparatus for gavage. 



The indications for gavage are the feeding of premature or asthenic 
infants who are unable to otherwise take their food, cases of habitual 
or obstinate vomiting in which the infants, as shown by Kerley, may 
vomit the food when swallowed, but retain it when given by the tube. 
Occasionally following intubation or operations on the esophagus, feed- 
ing by gavage is necessary. During meningitis or conditions in which 
there is coma, forced feeding may be indicated; as rectal feeding, 
except for a day or two, is of little value in early life. 



92 DISEASES OF CHILDREN. 

The food used may be breast milk, full strength or diluted, modi- 
fied or peptonized cow's milk, plain or dextrinized gruels. The 
amounts should be somewhat below the usual requirements and the 
periods of feeding lengthened. Care should be taken that the food 
is sufficiently warmed when it enters the stomach, as a luke-warm 
temperature is apt to induce vomiting. 

Rectal Feeding — Nutrient Enemata. 

Rectal feeding is rarely of service except for temporary use, 
as very little nutriment is absorbed. It may be possible to check 
body waste by this means, but we have never seen increase in weight 
when this was the only form of feeding. It is indicated in cases of 
cyclic or incessant vomiting or where there is an inability to swallow, 
in certain operative cases and when the food is not tolerated by the 
stomach. 

Method. — The rectum should be cleansed with a bland enema, as 
saline solution, and an interval of at least a half-hour should be allowed 
before injecting the food into the rectum. The child is placed on 
his back or left side with the thighs well elevated. The prepared 
food is allowed to flow into the rectum from an ordinary fountain bag 
to the end of which has been attached a small-sized colon tube or large- 
sized catheter. If the anus and tube are well anointed with vaseline 
the tube may be advantageously passed well up into the colon. If 
this is slowly and gently done, peristalsis will not be excited, and the 
contents of the bag held just high enough to permit a flow will be 
more apt to be retained. 

Infants will retain about two to six ounces, young children four 
to ten ounces. These enemata may be given three or four times in 
the twenty-four hours. Smaller amounts are always better tolerated 
and retained than larger quantities. When the rectal tube is with- 
drawn the buttocks should be pressed together, the child still retaining 
the recumbent posture. The fluids that may be used are peptonized 
or pancreatinized milk, eggs, albumin and gruels, or a combination of 
these. Occasionally stimulants or other drugs may be added to the 
food. 

Vaccine Therapy. 

The pathogenic action of any organism is almost entirely depend- 
ent upon the toxins which it produces. The most important fea- 
ture of the bacterial toxins is its relation to immunity. An animal 



GENERAL THERAPEUTICS. 93 

immunized to the action of a toxin is also protected against the patho- 
genic action of the bacterium which produces it. The toxins fall into 
two main groups: the extracellular soluble toxins (exotoxins) and the 
intracellular insoluble toxins (endotoxins). 

The exotoxins are given off in a free state when the bacteria are 
grown in a suitable medium, and can easily be separated by means of a 
porcelain filter. They are not formed by all pathogenic bacteria. The 
most important examples of toxins belonging to the exotoxin group 
are the Bacillus diphtheriae and Bacillus tetani; and it is in this group 
that the antitoxins are most easily developed and are most potent. 

The group of the endotoxins is a much larger one, and it is with 
this type that a great deal of experimentation with the vaccines has 
been undertaken. The endotoxins are present in the bodies of bacteria, 
whether the latter have been killed by heat, by antiseptics, or by dry- 
ing. This whole subject is further complicated by the fact that when 
bacteria are injected into a living animal they meet with resistance on 
the part of the host, and under these circumstances may produce 
protective substances which are toxic. This may in part account for 
the disappointing results which so frequently follow the use of a 
vaccine. 

All individuals have a certain amount of natural resistance to 
infection, and the effort with vaccines is to increase this resistance. 
The protective substance which exists in the blood is called opsonin, 
and its function is the preparation of bacteria for ingestion by the 
leukocytes. During an infective process the amount of opsonin is 
below normal. Dead bacteria from a culture of the infective organ- 
ism are injected into the infected individual for the purpose of increasing 
the opsonins to normal or above normal, and by thus rendering the 
blood rich in protective substance to hasten immunity. Immediately 
after injection resistance is on the whole lowered, and this is known 
as the negative phase, following which the resistance increases. In 
order to avoid giving a second injection during this negative phase 
Wright devised a method for measuring the opsonic power of the 
blood. This method is cumbersome, difficult and at best uncertain; 
and at the present time has been largely given up. In its place has 
been substituted a careful study of the clinical symptoms, and this 
method perhaps gives sufficient indications for the timing of the dose. 
In any case it is probable that the importance of the so-called cumula- 
tive negative phase has been exaggerated. Still it must be con- 
fessed that there is very little aggreement among those who are using 
vaccines as regards either the size or the spacing of the dose. 

The preparation of a vaccine is comparatively simple. The 



94 DISEASES OF CHILDREN. 

organism to be used is grown in pure culture. The culture is taken up 
in physiological salt solution, which is shaken until evenly distributed, 
after which it is standardized so that each c.c. contains a definite 
number of bacteria. These bacteria are then killed by heating to 
60° C. for one-half hour, and 0.5 per cent, of carbolic acid is added 
as a preservative. 

In children a smaller dose is given than to adults, and as usual 
this is based on age. The dose varies, however, according to the 
organism injected. It might be added that larger doses are rarely 
followed by disturbing symptoms, and there are indications that the 
present dosage of vaccines is too small. 

Unfortunately the statistics as regards vaccines are not very 
reliable. The occasional brilliant result in an isolated case may be 
due to the part nature plays in affecting a spontaneous cure, while on 
the other hand where no results are obtained there is nothing to 
publish. Also it is certain that overzealousness in trying a new remedy 
has frequently eclipsed the better judgment of the observer. 

Scarlet Fever. — In scarlet fever the Russians have apparently 
achieved remarkable results by preventive inoculations with a vaccine 
made from a bouillon culture of streptococcus isolated from a person 
ill with scarlet fever, and killed by heating to 60° C. These vaccines 
were used in Russian villages in scarlet fever epidemics in which from 
15 to 57 per cent, of the uninoculated were stricken with the disease. 
Of those who had received three injections of the vaccine none were 
affected; of 2,034 who had received two or more vaccinations, only two 
were attacked; of 2,737 others who had received only on injection of the 
vaccine, forty-one were attacked. Most of , those cases who had 
received vaccine treatment ran an exceedingly mild course. The 
immunity following three injections is supposed to last about one 
and one-half years. 

These figures are not only important from a prophylactic stand- 
point, but also serve as a strong indication of the etiological cause 
of scarlet fever. 

Typhoid Fever. — Available statistics indicate that prophylactic 
vaccination against typhoid is an invaluable measure. The duration 
of the immunity conferred is not as yet determined, but it is probably 
about three years. The reaction to this vaccination is only occasion- 
ally quite severe; there being malaise, fever and soreness at the point 
of injection. 

As regards vaccination during the course of the fever itself there 
is a great difference of opinion, the consensus of opinion being that it is 
of no value. However, there is reason to think that the dose has been 



GENERAL THERAPEUTICS. ' 95 

much too small and perhaps the results would have been better 
if 200,000,000 or 300,000,000 had been used instead of the usual dosage 
of 30,000,000 or 50,000,000. 

Septicemia and Septicopyemia. — Its treatment with autogenous 
vaccines has seemingly been of great value in many cases. Certainly 
a blood culture should be made in all of these cases and the effects of 
a vaccine tried. 

Empyema. — In chronic cases an autogenous vaccine is frequently 
of great value. Stoner has collected twenty-eight cases from the 
literature on the subject of which sixteen were cured, four improved, 
and eight were not benefited. In all of these cases the condition had 
persisted for some time. 

Pneumonia. — As pneumonia is a self-limiting disease it is difficult 
to draw any conclusions as to the value of the vaccine treatment. In 
adults, however, the mortality has been decreased about 8 per cent. 
Little or no attempt has been made to treat children in this manner. 
There are several reasons for this, the chief of which is the varied 
infective causes of the pneumonia, which entails the considerable 
delay of making an autogenous vaccine for each case. The difficulty 
of obtaining a proper specimen might also be mentioned. 

Acute Ulcerative Endocarditis. — If a positive blood culture is 
obtained benefit may be hoped for by the use of an autogenous vac- 
cine. About one-third of the cases will show no improvement. Out 
of six cases treated by Wright two were cured, one improved and three 
were not affected one way or the other. 

Adenitis. — The cases of acute adenitis are too few to allow of any 
conclusions. 

In tuberculous adenitis the tuberculin treatment seems to be of 
some value. This is especially true if treatment is begun before the 
gland begins to break down. 

Pyelitis and Cystitis. — The result of treatment with vaccines in 
both of these conditions is very good. The improvement usually 
begins promptly, the frequent urination, pain, etc., disappearing 
quickly. It is, however, practically impossible to cause a total dis- 
appearance of the pus and bacilli. 

Vaginitis (Specific). — Hamilton recently published some very 
gratifying figures as regards the treatment of vaginitis in children, 
the only difficulty being that no one has been able to duplicate them. 
In other hands the vaccine treatment in this condition has proven 
valueless, or nearly so. 

Furunculosis. — The vaccines are of benefit in this condition. No 
other method of treatment will give such satisfactory results, although 



96 



DISEASES OF CHILDREN. 



it must be born in mind that for some unknown reason a small per- 
centage of cases will not react. 

Acne. — Vaccines will cure a large percentage of these cases. In 
nearly every other case there will be some improvement, but here and 
there a case will be met with in which the vaccine will exert no ap- 
parent influence. 

Mastoiditis and Otitis Media. — When other means fail a vaccine 
may be tried. There is much difference of opinion as to whether they 
are of any value, the consensus of opinion apparently being that they 
do little good. 

Nearly all those who have worked with vaccines disagree as to the 
dosage. It would be a distinct advantage if there could be some 
uniformity of dosage, but in examining the literature it is found that 
one man is treating furunculosis with 10,000,000 dead staphylococci 
while another gives a dose of 1,000,000,000. Naturally the question 
arises as to Avhether the dose which the one man gives is not so large 
as to actually do harm while that given by the other is much too small 
to be effective. There is the same disagreement as regards the spac- 
ing of the dose, some giving it every day and others every two weeks. 
For these reasons the following table based on work done under our 
direction is given as a tentative one: 



Organism 



Dose 



Space between doses 



Staphylococcus. 
Streptococcus . . 

Pneumococcus.. 



Gonococcus 

Typhoid bacilli. 

Bacillus coli . . . , 



100-1,000 million 
5-12 million 
25-50 million 
50-250 million 
(infant 10 million) 



Acute, 5-50 millions 

Chronic, 50-500 million 

Immunity, 750-2,000 million 



Treatment, 



40-250 million 
10-50 million 



Ten to fourteen days. 

Daily. 

Every tenth day. 

Seven to ten days. 

In pneumonia smaller doses at 

more frequent intervals should 

be used. 
Seven to ten days. 

In two doses at fourteen days 

interval. 
Every other day. 
Eight to twelve days. 



Stock vaccines may be used if the diagnosis is established, until 
such a time as is necessary to prepare an autogenous vaccine. It should 
be born in mind, however, that they are not as satisfactory as those 
prepared directly from cultures of the infecting organism. 

Breathing and Resistant Exercises. 

While special physical training is important and often opportune 
in the cure of deformities and badly-developed children, a greater 



GENERAL THERAPEUTICS. 



97 






Fig. 24. — Exercises for developing children with deformities: ^a) narrow flat 
chest in a mouth breather; (b) showing winged scapulae and curvature; (c) and 
(d) corrective exercises. 
7 



98 



DISEASES OF CHILDREN. 



proportion of all children need some systematic training in the act of 
correct breathing and instruction as to correct posture. 

The schools in some of the larger cities are making some valuable 
efforts along these lines, through physical directors who have made a 
study of life during the developmental stage. At this time good habits 
are easily inculcated; later, in adult life, they are brought about 
only with difficulty and the expenditure of valuable time. 




Fig. 25. — Exercises useful for increasing respiratory capacity. 



If breathing as an art is taught the child, it will develop its lung 
capacity and supply the proper amount of oxygen to the growing 
tissues. Each breath should be taken in slowly through the nostrils 
in as large a c^uantity as is comfortable without effort; gradually this 
amount is increased as the natural elasticity of the lungs is increased, 
and in a short time, with thought and practice, diaphragmatic breath- 
ing becomes the natural breathing the child. 

In the Logi method, the patient lies on the floor upon a sheet, 
with windows wide open and clothing perfectly free. One nostril is 
closed and an inhalation taken and held a few seconds before exhaling 
through the opposite nostril, and this is repeated several times with 
frequent pauses for rest and diversion. 



GENERAL THERAPEUTICS. 99 

The next step is the development of intercostal breathing; later 
the accessory breathing muscles are utilized, and finally the so-called 
complete breathing is perfected. The best results are obtained when 
individual instruction is given by a competent teacher. 

The parents may later act as monitors and encourage the chil- 
dren to go through their exercises daily. As a rule, the little patients 
delight in this, and consider it a pleasure rather than a task. By con- 
tinuing slow, resistant exercises with the deep diaphragmatic breath- 
ing, placing the pupil before a mirror and teaching him to concentrate 
his mind upon each movement, the general tone of the body can be 
markedly raised. Twice a week for fifteen-minute periods usually 
suffices in the beginning. 

The aim should not be to produce great muscular development, but 
simply to create a natural demand for proper food, improve the 
general circulation, and bring about better health. 

The indications for these exercises are many, but the best results 
are obtained in children who are shallow mouth-breathers as a result 
of various disorders of the respiratory tract or of nutrition. We have 
had excellent results with this method following adenoid operations^ 
in rachitic and anemic children with perverted appetites. Neurotic 
children react very favorably. 



CHAPTER X. 

SUGGESTIVE SCHEME FOR DIAGNOSIS. 

To confirm the suggestions for diagnosis in this table the reader 
can refer to the section that treats at length of the diseases suggested. 

Head. 
Size. 

(a) Small — Microcephalus, idiocy. 

(6) Large — Hydrocephalus, rickets, hypertrophia cerebri. 
Shape. 

(a) Square — Rickets. (Prominent frontal eminences.) 

(b) Asymmetrical — Rickets, cretinism, idiocy, brain tumors, 
atrophy of brain. 

(c) Bulging Forehead — Hydrocephalus. 

(d) Prominent Frontal and Parietal Bones — Syphilis. 

(e) Craniotabes — Syphilis, rickets, chondrodystrophy. 

(/) Open Sutures — Rickets, hydrocephalus, cretinism, idiocy. 
Position. 

(a) Retraction — Meningitis, Pott's disease. . 

(b) Lateral Deviation — Wry neck, rheumatic torticollis, Pott's 
disease, injury to neck muscles at birth, abscess. (Peri- 
tonsilar, postpharyngeal or of cervical glands.) Middle 
ear or mastoid, hematoma, sternomastoid, curvature, 
hysteria. 

Motion. 

(a) Purposeless Movements — Chorea, tics. 

(b) Rythmic — Nodding spasm. 

(c) Flaccidity — Anterior poliomyelitis, coma, late meningitis. 
FontaneL (Normally open till eighteenth month.) 

(a) Bulging (during cry normal) — Hydrocephalus, meningitis, 

hemorrhages within, brain tumor, thrombosis of sinus. 
(6) Depressed — Atrophic constitutional diseases, severe diar- 
rhea, first stages of meningitis. 
Tumors. (About the head.) Hematoma, abscess, sarcoma, syphilis, 
encephalocele, hydromeningocele, hernia cerebri. 

100 



SUGGESTIVE SCHEME FOR DIAGNOSIS. 101 

Neck. 
Tumors. (About the neck.) 
(a) Parotitis. 
(h) Lymph node hypertrophy. 

(c) Thyroid enlargement. 

(d) Branchial cleft. 

(e) Congenital cysts (blood cysts, angiomata, hygroma). 
(/) Hematoma (especially of the sternomastoid). 

Face. 
Expression. 

(a) Pain (intermittent) — Colic, dentition, dysuria, otitis, bodily 
discomfort. 

(b) Pain (continuous) — Pneumonia, pleurisy, peritonitis. 

(c) Pain (on handling) — Scurvy, fracture, dislocation, rickets, 
spinal paralysis, meningitis, neuritis, rheumatism. 

(d) Anxious — Obstructed breathing or dyspnea from any cause; 
heart disease.' 

(e) Cretinoid — (Thick lips, protruding tongue, stolid). 

(/) Sad — (spirit uelle). Tuberculosis and chronic diseases. 
(g) Disgust — Dyspepsia, gastritis, abdominal disease. 
(h) Senile — Marasmus, syphilis, internal hydrocephalus. 
(i) Pinched — (abdominal). Peritonitis, cholera infantum, pro- 
longed or severe diarrhea, collapse, 
(j) Foolish — Idiocy. 
(A:) Stupid — (fish mouth). Adenoids. 

Mouth. 
Open Mouth. 

Cretinism, rickets, idiocy, coryza, inflammation of the throat. 
Lips. 

Enlarged. — Cretinism, syphilis, adenoids and hypertrophied ton- 
sils, infection, neoplasms. 
Fissures and Ulcerations. 

Syphilis, stomatitis, after and during acute infectious diseases, 

injuries. 
Tongue. 

Enlarged. — Congenital, cretinism, idiocy, inflammatory processes, 

trauma, infection. 

Fissures and Ulcers. — Syphilis, caries of the teeth, tuberculosis, 

stomatitis, ulcer of frenum. 



102 DISEASES OF CHILDREN. 

Enlarged Papillce. — Strawberry tongue of scarlet fever, diabetes, 
lymphatic leukemia, status lymphaticus. 
Geographical. — Intestinal fermentation, tuberculosis. 

Gums. 

Swollen, Bleeding or Spongy. — Gingivitis, acute infectious diseases, 
scurvy, congenital heart disease, leukemia, stomatitis, difficult 
dentition, caries of the teeth, neoplasms. 

Teeth. 

Syphilis (Hutchinson's teeth), cretinism (small pointed), severe 
chronic diseases (notches, ridges, rings). Delayed dentition; 
rickets, syphihs (in infancy). Chronic diseases of infancy. — 
Loosening and shedding in scurvy, mercury, caries. 

Swallowing. 

(a) Pseudodysphagia. 

Nasal obstruction, sore mouth, parotitis, adenoids, pyloric steno- 
sis, anorexia. 

(6) True Dysphagia. 

Paralysis of soft palate, pharynx or tongue. 

Spasm of muscles in tetanus, chorea, strychnin poisoning, hysteria, 

Thomsen's disease. 

Swellings of tonsils. Peritonsillar abscess. Angina, mediastinal 

glands, thyroid, thymus. 

Macroglossia. — Cretinism. 

Corrosion. Cicatrix. Heat, drugs, syphilis, tuberculosis, trauma, 

ulcer, foreign body. 

Congenital Defects. — Atresia, stenosis, diverticula. 

Abnormalities in Breathing. 

Mouth Breathing in Nasal Obstruction. 

(Noisy breathing, snoring) narrowing or obliteration, congenital 
obstruction, cretinism, syphilis, deformities, chondrodystrophy, 
adenoids, polypus, foreign bodies, hematoma, tuberculosis, lupus, 
abscess, rhinitis acute and chronic, injuries. 

Inspiratory Dyspnea. 

(a) Pharyngeal Stenosis. — Enlarged tonsils, chronic neoplasms, 
retropharyngeal and peritonsilar abscess. Phlegmon diph- 
theritic, cold abscess, tuberculous glands, vertebral caries, 
macroglossia, ranula, neoplasms of tongue and jaw. 



SUGGESTIVE SCHEME FOR DIAGNOSIS. 103 

(6) Laryngeal Stenosis. — Diphtheria, spasmodic laryngitis (croup), 
laryngo-spasm with crowing inspiration, tetany, rickets, 
hydrocephalus, enlarged bronchial glands, status lymphaticus, 
membrane in scarlet and measles, tuberculosis, syphilis, neo- 
plasms, urticaria, foreign bodies, drugs, scalding, corrosion, 
edema glottis, edema from renal and cardiac disease, goiter, 
paralysis. 

(c) Tracheal and Bronchial Stenosis. — Diphtheria, enlarged bron- 
chial glands, thymic disease, goiter. 

Expiratory Dyspnea. 

Emphysema, asthma, spasm of inspiratory muscles, tetanus, tet- 
any, epilepsy, hysteria, convulsions (irritation phrenic nerve 
in pericardial effusion). 

Mixed Dyspnea. 

Bronchitis, pneumonia, pulmonary edema, pleurisy, tuberculosis, 
heart disease, the anemias, toxic and acute infectious diseases, 
diabetic coma, uremia, gas poisoning, heat stroke, organic lesions 
of pons and medulla, tumors, abscess and hemorrhages of brain, 
anterior poliomyelitis with cerebral symptoms. 



Chest. 

Shape. 

(a) Barrel Shape. — Emphysema, pertussis, asthma, bronchiecta- 
sis, chronic bronchitis, pneumothorax. 

(h) Contracted Chest. — Rickets, tuberculosis, stenosis of upper 
respiratory tract as adenoids and stenosis of larynx. 

(c) Bulging Sternum (pigeon breast). — Rickets, heart disease, 
pertussis, stenosis alone. 

{d) Asymmetrical. — Pleural effusions, pneumothorax, pleural 
adhesions, scoliosis. 

(e) Funnel Shape. — Rickets, intraabdominal pressure. 

(f) Harrison^ s Groove. — Rickets. 

Tumors of Chest Wall. 

(a) Pointing empyema, caries of spine, bronchial glands, periosti- 
tis. 

(6) Breast — (Milk distention, septic mastitis, mumps, true 
tumors.) 

(c) Bulging precordia, heart disease, pericarditis. 

(d) Hernia of lung. 



104 DISEASES OF CHILDREN. 



Abdomen. 



General Enlargement or Prominent Abdomen. 

(a) Distention with Gas. — Dyspepsia, gastritis, pyloric stenosis, 
intestinal indigestion and dysentery, intestinal obstruction, 
constipation, tuberculous and septic peritonitis, pneumonia, 

, typhoid, congenital dilatation of colon, obstructed hernia, 

intestinal perforation. 

(b) Fluid. (1) Peritonitis (chronic, serofibrinous, tuberculous, 
ill septic (from umbilicus), gonorrheal, pneumonic. 

(2) Heart disease (uncompensated heart and chronic adhe- 
sive pericarditis). 

(3) Kidney diseases. 

(4) Hepatic diseases (cirrhosis, true tumors, degeneration). 

(5) Portal obstruction (enlarged glands, adhesions). 

(6) Grave anemias. 

.|l (c) Constitutional Diseases. — (Usually from weak spine.) Rickets, 

cretinism, syphilis, marasmus. 

(d) Miscellaneous. — Pott's disease, curvature, congenital dis- 
location of hip. Hysteria. 

(e) Enlarged liver and spleen. 

Enlarged Liver. 

(1) Hyperemia in Sepsis. — Cardiac and pulmonary affections. 

(2) Toxic. — (a) Alcohol, phosphorus, santonin. 

(b) acute infectious diseases. 

(3) Constitutional Diseases. — Tuberculosis, syphilis, rickets, ath- 
repsia. 

(4) Cirrhosis. — (Acute yellow atrophy.) 

(5) The Anemias. — Leukemia, pseudoleukemia, splenic anemia, 
Banti's disease, primary splenomegaly. 

(6) Abscess, cysts and true tumors. 

Enlarged Spleen. 

(1) Acute infectious diseases. 

(2) Constitutional diseases (as above). 

(3) Hepatic, cardiac and pulmonary (as above). 

(4) The anemias (as above). 

(5) Abscess, cysts and neoplasms. 

Localized Tumors. 

(a) Kidney. — Floating kidney, hydronephrosis, pyelitis, peri- 
nephritis, neoplasm, cystic kidney, tuberculosis. 

(6) Stomach and Intestines. — Pyloric stenosis, intussusception, 



SUGGESTIVE SCHEME FOR DIAGNOSIS. 105 

appendicitis, impacted feces, worms, neoplasms, congenital . 
dilatation of colon, 
(c) Miscellaneous. — Thickened omentum (tuberculous peritoni- 
tis) mesenteric glands, psoas abscess, encysted peritoneal 
abscess, distended bladder. 
Tumors of Abdominal Wall. 

Abscess, hematoma, hernia (muscular). 
Umbilical Region. 

(1) Hernia (of omentum, intestines, bladder). 

(2) Fungus (granulations). 

(3) Periumbilical abscess. 

Inguinal Region. 
Tumors or Enlargements. 

Hernia, hydrocele of tunica vaginalis and cord. 

Undescended testicle. 

Orchitis, mumps, syphilis, tuberculosis, influenza, trauma. 

Neoplasms. 

Varicocele. 

Delayed Growth. 
(a) Improper feeding and digestion, starvation, pyloric stenosis, 

marasmus. 
(h) Cretinism, rachitis, idiocy, infantilism, osteomalacia, micro- 

melia. 

(c) Tuberculosis. 

(d) Syphilis. 

(e) . Valvular heart disease. 
(/) Progressive paralysis. 

Hemorrhages. 
1. General Causes. 

(1) Acute Infectious Diseases. — Pyemia, septicemia. 

(2) Toxic. — lodids, mercury, ergot, belladonna, phosphorus, 
antipyrin, chloral, arsenic, food poisoning, snake bites. 

(3) Constitutional Diseases. — Syphilis, scurvy, Bright's disease, 
tuberculosis, athrepsia, cachexia. 

(4) Purpura. — Purpura simplex, fulminans, hemorrhagica rheu- 
matica, Henoch's purpura. 

(5) Blood Diseases. — Hemophilia, leukemia, pseudoleukemia, 
splenic anemia, Banti's disease, severe secondary and perni- 
cious anemia. 

(6) Mechanical. — Injury, pertussis, epilepsy, at birth. 



106 DISEASES OF CHILDREN. 

2. Special Causes. 

(a) Of New-horn. — Asphyxia, obstetrical operations, deficient 
expansion of lungs, sepsis, syphilis, hemophilia, congenital 
disease of liver and bile ducts. 

Q)) From Nose. — 

(1) In new-horn as ahove. 

(2) Affections of mucous membrane. Traumatism, foreign 
body, acute and chronic rhinitis, adenoids, polypus, diph- 
theria, measles, worms. 

(3) Congestion, prolonged cough. Cardiac and pulmonary 
affections. Overheating, nephritis, sinus thrombosis. 

(4) Prodromal, in acute infectious diseases. 

(5) Vicarious menstruation. 

(6) Fractured skull. 

(c) Of Stomach. — Gastric ulcer, chemical erosions, worms, foreign 
body. Occlusion of intestines, swallowed blood, general 
causes as in 1. 

(d) Rectum. — General causes and new-born. Severe enteritis, 
gastric and intestinal ulcer, follicular and membranous enteri- 
tis, worms, intussusception and strangulation, hemorrhoids, 
polypus, anal fissure, condyloma, prolapse rectum, injury 
with enemata, etc., typhoid, tuberculosis. 

Extremities. 
1. Disturbances of Motion. . 

(a) Paralysis or Pseudoparalysis. — Anterior poliomyelitis, scurvy, 
syphilis, rickets, postdiphtheria, cerebral palsy, neuritis, birth 
palsy, meningitis, fracture, epiphyseal suppuration, osteo- 
myelitis, spina bifida, transverse myelitis, progressive mus- 
cular atrophy. Landry's paralysis. 

(h) Inahilityt: Walk or Walk with Limp. — (Any of the above pa- 
ralyses cited in (a) ). Delayed walking. Tuberculosis of the 
hip,, knee, ankle. Pott's disease, osteomalacia, congenital 
dislocation of the hip, rickets, coxa vara, rheumatism, mental 
deficiency, idiocy, hydrocephalus and microcephalus, cretin- 
ism, weakness after disease or poor nutrition, progressive 
muscular atrophy, flat-foot, improperly fitted shoes. 

(c) Spastic Extremities (rigidity). — (Normal in early infancy.) 
Gummata, cerebral hemorrhages, sclerosis, tumors, spastic 
paraplegia, acute encephalitis, Little's disease, hydrocephalus, 
meningitis, lateral sclerosis, hereditary ataxia, tetany, cata- 
lepsy, tetanus. 



SUGGESTIVE SCHEME FOR DIAGNOSIS. 107 

2. Swellings. 

(a) Joints. — Chronic and acute polyarthritis. (Rheumatic, puru- 
lent, gonorrheic, following scarlet fever and pneumonia). 
Tuberculosis of the joints, simple effusion, bursitis. 

(b) Bones. — Rickets (epiphyseal), syphilis, scurvy (subperios- 
teal). Osteomyelitis, neoplasms. 

(c) General Enlargement. — Anasarca, angioneurotic edema, sepsis, 
hydremia, acromegaly, elephantiasis, erysipelas, cretinism. 

3. Hands. 

(a) Dactylitis. — (Simple, tuberculous, syphilitic.) 

(b) Clubbed Fingers. — Heart disease, chronic cough, hepatic cir- 
rhosis. 

(c) Claw Hand. — Ulna paralysis, progressive atrophy, lesions 
spinal cord, ischemic paralysis. 

{d) Purposeless Involuntary Movements. — Chorea (infectious and 
hereditary, Huntington's). Organic brain lesions (hemi- 
plegia, tumors, abscess brain, sclerosis after meningitis). 
Friedrich's ataxia, habit spasm, idiocy, hysteria. 



SECTION VI. 
INFANT FEEDING. 



CHAPTER XI. 
THE INFANT FROM THE NUTRITIONAL STANDPOINT.* 

Introduction. — It is coming to be an important part of a physician's 
work to look after the feeding of infants, and as much if not more knowl- 
edge is required to do this successfully than is called for in writing 
prescriptions for drugs for diseases. No one can become a good infant 
feeder who is not well-grounded in the principles of nutrition, partic- 
ularly as they apply to infants, or who has not served an appren- 
ticeship under a successful feeder and learned the art of infant 
feeding, even if he has not mastered the science. As a principle may 
oftentimes be applied in different ways and as methods that are ap- 
parently contradictory may produce essentially the same results, 
a section will be devoted to the elementary principles involved in the 
management of all infants, so that confusion will not be caused by the 
apparently contradictory statements of other authors. The essential 
sameness of many substances and procedures which are to all appear- 
ances diametrically opposed to each other will then be recognized. 

The Infant. — To thoroughly understand the management of in- 
fants one must fully realize the position of the infant in the life history 
of a human being. A normal life history, from a biological standpoint, 
commences at conception and ends at death due to old age. The prob- 
lem of nutrition begins when the fertilized ovum starts to divide and 
form additional cells, and from this time on until death there is an un- 
ceasing demand for food. During a life history the food is supplied in 
many different forms, and as the organs of nutrition change in the 
earlier stages of development, the physical properties of the food 
change also. Fig. 26 is intended to show the different forms of food 
utilized by the human being during its life history and the organs 
of nutrition used at different stages of development. In the earliest 
stages the food is supplied from the yolk of the ovum; as development 
progresses, the villi of the chorion appear and act as organs of nutri- 

*For greater details in reference to the biology of this subject, see ''Theory 
and Practice of Infant Feeding," by Dr. H. D. Chapin. Third edition. WilHam 
Wood & Co. 

108 



THE IXFAXT FROM THE NUTRITIONAL STANDPOINT. 



109 



tion; these gradually merge into the placenta which derives food from 
the maternal blood; at birth the breasts supply food in the form of 
colostrum for a few days, which is gradually displaced by milk. When 
the milk supply naturally 'fails, toward the end of the first year, the 
child is capable of digesting some forms of semisolid food such as its 
parents eat, and continues its development on this food. 



FIRST NUTRITIVE PERIOD 




isr 


2ND 


3R0 


4-TH 


OVUM 


CHORION 


PLACENTA 


BREASTS 


YOLK 


YOLK AND SERUM 


MATERNAL BLOOD 


COLOSTRUM AND MILK 



SECOND NUTRITIVE PERIOD 



(g 




<^^^ 



5TH 6TH 

milk; BREAD. CEREALS. EGGS - SOUP, FISH.MEAT.VEGETABLES.FRUIT. NUTS 



Fig. 26. — Nutritive life history, 



Life Divided into Two Nutritive Periods. — From the illustrations in 
Fig. 26 it will be observed that the life of a human being is sharply 
divided into two parts : First, that which is marked by the food being 
derived entirely from the mother; second, that in which none of the 
food is supplied by the mother. It will also be noticed that during the 
period in which the food is supplied exclusively by the mother, there 
is a rapid change in the form and complexity of the organization of 
the fetus or infant, and that the form in which the mother furnishes 
the food, the organs through which she supplies it, and the organs of 



110 DISEASES OF CHILDREN. 

nutrition of the fetus and infant undergo great changes. In a word, 
the mother changes the food to suit the condition and organs of the 
developing infant, and not until the digestive tract is developed suffi- 
ciently to be able to utilize semisolid food does the normal mother 
cease to nourish her offspring with special forms of food. 

The second nutritive period begins when the child is able to 
secure enough nutriment from semisolid food, and this period is 
marked more by general increase in size than by profound structural 
changes or the development of new nutritive functions. 

Table Showing Derivation of Tissues of Man Weighing 180 Pounds. 

(Schematic.) 
Conception to weaning (first nutritive period): 
Ovum 1 

Chorion [ supply 8 pounds (birth weight). 

Placenta J 

Breasts supply , 12 pounds 

20 pounds (weight at weaning). 
Weaning to maturity (second nutritive period): 
Milk, eggs, cereals, meat, 1 „„„„i„ ^ar) 

fish and vegetables / ^^PP^^ i^ 

Total 180 pounds (weight at maturity). 

Essential Unity of Foods. — When all forms of food, including 
mother's milk, are subjected to chemical analysis they are found to be 
composed of ingredients which fall into five groups : Proteins, often- 
times termed proteids, which form the tissues; 
mineral matter which is necessary for bone 
formation, and also in lesser quantities to 
replace metabolic waste; fats and carbohy- 
drates which supply the energy; and water. 
The great difference in foods at different ages 
is not one of composition, hut of form. 

Foods of the First Nutritive Period. — The 
mother supplies food to her offspring in six 
different forms: First, the yolk of the ovum; 
next the fluid in which the ovum is bathed; 
then that which is supplied in a form suited 
for assimilation by the chorion; and then fetus^' of kang^aroo-Mfe 
by blood which circulates through the pla- size. (Parker and Has- 
centa. When birth occurs, the food is sup- ^^ '^ 
plied through the breasts in two forms, at first colostrum and finally 
as milk. 

Each of these forms of food is specially adapted to the infant 
at the time it is furnished, and as soon as the infant outgrows one 
form of food another is supplied. 






THE INFANT FROM THE NUTRITIONAL STANDPOINT. Ill 

The Infant a Mammary Fetus. — While the infant is looked upon 
as a fetus until birth, it is, in a broader sense, a fetus until it is capable 
of subsisting on soft food, or, in other words, until its digestive appa- 
ratus is developed. Fig. 27 shows the fetus of the kangaroo. This 
animal has no placental connection with its mother; it is born in an 
exceedingly rudimentary state of development, and then grows fast 




Fig. 28. — Head of mammary fetus, hemisected to show adaptation of teat to 
miouth. {From a specimen, Columbia University.) 

to the nipple, at which it develops from the size of a young mouse 
to a weight of about seven pounds, when it is able to secure food for 
itself and becomes independent of its mother. In the early stages 
of the mammary development of the kangaroo the mother ejects the 
food into the esophagus which at this time has no connection with the 
air passages (Fig. 28). As the development advances the fetus 
ceases to be adherent to the nipple and obtains nourishment hy 



112 



DISEASES OF CHILDREN. 



sucking. At one time this type of animal predominated, but now 
placental forms so far outnumber them that they have become rare. 

If the infant was born about the time the placenta develops and 
then became adherent to the nipple it would be nourished much Hke 
the young kangaroo, and the importance and place of breast-feeding 
would be self-evident. The young of implacentals are still in the 
fetal stage at birth, and also after the mouth ceases adhering to the 
nipple, which corresponds to the time of birth or when the placenta 
separates from the mother in placental animals. For some time after- 
ward they depend upon the mother for nourishment. Therefore from 
a nutritive standpoint the infant is as much a fetus as is an impla- 




FiG. 29. — Colostrum corpuscles. 

{Jewett.) 



Normal human milk. 
(Jewett.) 



cental animal after it is developed sufficiently to suck, and this fact 
should be kept in mind. 

Breast Secretions: Specialized Foods. — From the illustrations in 
Fig. 26 it is plain that before birth the form of the food supplied by 
the mother and the method of furnishing it change to suit the state of 
development of the fetus; and as at birth the digestive organs of the 
infant are not fully developed, it may be concluded that in some way 
the breast secretions are peculiarly adapted for that part of the first 
nutritive period in which the digestive tract is developing. 

Composition and Properties of Breast Secretions. — The first 
secretion of the breasts or mammary glands after the infant or young 
animal is born is called colostrum. Chemical analysis shows it to be 
composed, like all foods, of proteins, mineral matter, fats, carbohy- 
drates, and water. 

Upon boiling, colostrum coagulates, owing to a large portion of 



THE IXFAXT FROM THE NUTRITIONAL STANDPOINT. 



113 



the protein being in the form of albumin. It is also distinguished by 
the presence of colostrum corpuscles (Fig. 29). In the course of a 
few days after birth the character of the breast secretion undergoes a 
complete and radical change. The later secretion is milk, which is also 
composed of protein, mineral matter, fats, carbohydrates, and water, 
but it will not coagulate when boiled, showing there has been a change 
in the character of the protein, and the colostrum corpuscles are 
absent. From these facts it is evident that chemical analysis throws 
little light on the properties of either colostrum or milk, except to 
show that they are composed of the basic food elements. 

As the characteristic feature of nutrition during the first nutritive 
period is the adaptation of the form of the food by the mother to the 



Teeth and 
salivary glands. 



Stomach. 



Intestines. 




Fig. 31. — Development of human digestive tract. 
(Allen Thompson and Wiedersheim.) 



organs of nutrition of the fetus, which are constantly undergoing 
change, it is evident that the way to acquire a knowledge of the proper- 
ties of the breast secretions is to study them in the relations to the 
infant's digestive organs. 

Development of the Digestive Tract. — At birth the digestive organs 
are quite different both anatomically and physiologically from those 
of the adult. Teeth are absent, which in the adult reduce the food 
to a state of fine subdivision, to fit it for the stomach, and the gastric 
secretions particularly are not like those of the adult, and in some 
animals the stomach is not fully formed. During the colostrum period 
there is little gastric secretion, but when the mother secretes milk, 
the rennet ferment or rennin, which is closely allied to pepsin, is 
secreted in the stomach. Rennin prepares the milk for stomach 



114 



DISEASES OF CHILDREN. 



digestion by the infant in much the same manner as teeth prepare the 
food for digestion later in Hfe. That is, rennin acts upon a portion 
of the milk and changes it from a fluid into a semisolid which has on 
a small scale much of the physical property and texture of the chewed 
food of the adult. Until pepsin and acid are secreted, true gastric 
digestion does not take place and the solid remains very soft; but 
when acid appears it in some way combines with the solidified milk, 
rendering it more solid and fitting it for digestion by pepsin. Thus 
it is that the first solid food for the undeveloped digestive organs is 
produced from the specialized food supplied -by the mother, and its 
digestive properties are altered or adapted to the stomach by the 
gastric secretions. 




Fig. 32. — Stomach of different milk secreting animals. (Wiedersheim.) 



Comparative Anatomy and Physiology of Digestive Organs. — 

When the digestive organs of the lower mammals are compared it 
is found they differ greatly both in structure and in the methods 
by which they carry on the digestive processes. All animals digest 
proteins, mineral matter, fats and carbohydrates, and the chemical 
changes that take place in digestion are essentially the same in all 
forms of animal life, but methods of digestion show wide differences. 
In the early fetal stages the digestive tracts of all mammals are very 
much alike, but as development proceeds, anatomical differences are 
observed which become pronounced as maturity is approached. There 
are as wide differences in the digestive organs of animals as there are 
in the forms of their limbs and feet, and these differences assume great 
importance when it comes to selecting food for different species. From 



THE IXFAXT FROM THE NUTRITIONAL STANDPOINT. 115 

practical experience in feeding many kinds of animals at experiment 
stations the following principle has been deduced: the food must he 
adapted to the species. 

Comparative Mammary Secretions. — As far as known, all mam- 
mals secrete colostrum for a few days after birth takes place, and 
this secretion is followed gradually by milk, but the milks of different 
species show wide differences in their properties. When they are 
subjected to chemical analysis, it is found they all agree in being com- 
posed of proteins, mineral matter, fats, carbohydrates and water, al- 
though the proportions of these ingredients are not the same in all 
kinds of milk or in the milk of different individuals of the same species. 
To one wdio is not familiar with the methods of milk and food analyses 
it might appear from this that the differences betAveen milks of different 
species were due merely to the varying proportions of the food elements 
present, and for a time this was the behef held by some of the foremost 
pediatricians. But, when it was known how little idea of the prop- 
erties of a food is shown by the report of its chemical analysis, the 
limited value of food analyses in infant feeding was appreciated. 
The terms proteins, mineral matter, fats, carbohydrates, and water 
are about as definite as the terms wood, stone, glass, and metal used 
in describing the construction of a house, and comparing foods accord- 
ing to the proportions of the elements present is about as useful a 
procedure as comparing buildings by their composition. 

However, it must not be supposed that a chemical analysis of 
food or milk has no value, for it is of great importance, but its true 
value should be recognized and not overestimated. 

The proper way to compare milks for infant feeding is to see how 
they react to rennin, pepsin, and acid, and how they compare in compo- 
sition. Milks of different species when so compared show great differ- 
ences, although they may have identically the same composition; that is, 
be composed of the same quantities of proteins, mineral matter, fats, 
carbohydrates, and water. Human milk is changed into a semi- 
solid, finely divided mass by rennin, pepsin and acid; cow's, goat's, 
and sheep's milk into a solid mass which is of the same volume as the 
milk; mare's and asses' milk into a fluid jelly. This results from the 
action of rennin on a portion of the proteins generically termed casein, 
or by some caseinogen. When the digestive organs of the various 
animals are compared it is observed they are not alike either in form 
or in the manner in which they perform the digestive function, and it 
is found that the mother's milk is digested in much the same manner 
as the food will be digested after weaning, so the reason for the differ- 
ent physical properties of the various milks after they have been 



116 DISEASES OF CHILDREN. 

acted upon by the rennin ferment is apparent, and the fact that 
mother's milk is the ideal food for any young animal becomes self- 
evident. It is Nature's way of applying the rule — the food must be 
adapted to the species. 

If the peculiar adaptation of the milk to the digestive organs 
was not enough proof of the superiority of mother's milk, it would 
be found in the fact that the general composition of the milk of each 
species of animal is such that the milk is adapted to the rate of growth 
of the young. Animals that grow rapidly need larger quantities of 
proteins than those which grow more slowly and the mothers of 
animals whose growth is rapid secrete milk much richer in proteins 
than mothers of animals whose growth is slower. 

In practical feeding it is found that milks of different species 
are not interchangeable from a digestive standpoint, although they are 
all highly nutritive, but the reason was not discovered until infant 
feeding was studied from the standpoint of milk as a specially 
adapted food, and the subject was considered from a biological stand- 
point. 

Chemical and Biological Standards in Infant Feeding. — In the 
early days of scientific infant feeding it was believed that the differ- 
ences between all milks lay in the relative quantities of proteins, 
mineral matter, fats, carbohydrates, and water of which they were com- 
posed and in their reaction to litmus-paper, and that milks could be 
made interchangeable by readjusting their percentage composition 
and altering their reaction to litmus. For a long time this teaching was 
thought to be correct, but it began to be observed that it was often 
not followed in practice, and it was then taught that the great differ- 
ences between milks lay in the relative proportions of casein and albu- 
min which made up the proteins of milk. For a time this teaching 
was accepted by many, but it was found that caseins differed and 
that the term casein was about as definite as the term wood. By a 
play on words all milks could be made alike on paper, but actually 
they were different. 

There have been used from time to time various methods of 
making cow's milk agree with infants, such as adding lime-water, bi- 
carbonate of sodium, citrate of sodium, and peptonizing materials, 
which have produced chemical changes, each of which has been 
claimed to make cow's milk like human milk. These methods have 
been confusing and contradictory and have made the whole subject 
chaotic. The aim has been to make human milk by chemical means 
and the standards used in feeding until recently have been purely 
chemical. But as the effects of the different methods in practice have 



THE IXFAXT FROM THE XUTRITIOXAL STAX'DPOIXT. 117 

been studied it has been found that they do not make human milk^ 
but either change the character of the proteins of cow's milk, or alter 
the action of the digestive secretions of the infant on the milk^ so in 
reality while the theory has been that chemical changes Avere utilized 
to make human milk of cow's milk, practice, has been along the line of 
adapting food to the infant. Theory and practice haye been diamet- 
rically opposed and naturaib.^ great confusion was the result. 

Since the recognition of the fact that it is impossible to make 
human milk from other substances as yet, and that the practice is to 
adapt food to the infant, the biological standard of feeding has as- 
sumed greater importance and makes theory and practice coincide. 

This standard or principle may be stated as follows: 

At all stages of life the food must be composed of yroteins, viineral 
matter, fats, carbohydrates, and water. 

These elements exist in a great variety of forms which are equally 
nutritious, but are not equally adapted for the digestive organs at all 
ages, or for all species of animals, as their digestive organs are not alike. 

The peculiarities of the digestive organs must be first considered, and 
after this has been done food must be selected that is adapted for the 
particular digestive tract. 

After such a food has been found its composition must be looked 
after so that enough of the eleynents necessary to produce proper growth 
and development may be assured. 

Under this standard any procedure is scientific, provided it is 
employed with the understanding of its purpose, but if it is not one 
that cannot be continuously used without danger to the general well 
being of the infant it must be looked upon as a temporary expedient 
and the patient not dismissed until on a proper diet. 

In the treatment of practical feeding this plan will be followed, 
and the prominent position heretofore given to the sujDposed chemical 
differences between human milk and other foods will not be found in 
this work. The chemical side of feeding will be subordinated to the 
physiological aspect, for in practice all that the chemical composition 
of a food shows is its possible nutritive value, its actual value for each 
infant being a subject for determination by experiment with the 
infant. 

Recapitulation. — The main points to be kept in mind in infant- 
feeding are: 

The infant should be looked upon as a mammary fetus. 

The mother's breast secretions are specialized forms of food, 
adapted to the developing digestive organs. 

Milks of lower animals and table food are as nutritious as mother's 



118 DISEASES OF CHILDREN. 

milk, but are not adapted to the undeveloped condition of the infant's 
digestive tract. 

The chemical composition of a food shows nothing concerning its 
suitability for any animal and is not of first importance. 

The value of foods for individuals cannot be judged by comparing 
their chemical composition. 

Foods may be ''chemically right but practically wrong." 

The food elements required by all infants are the same, but the 
form in which they are to be presented must be determined for each 
infant by experiment. 

No infant is a law unto itself except concerning the form in which 
it prefers its food. 



CHAPTER XII 
BREAST-FEEDING. 

Importance of Breast-feeding. — Reference to Fig. 26 on pag^ 10^ 
will show that the breast secretions are the last of a series of specially 
suitable forms of food supplied by the mother during the period in 
which the organs and their functions are developing in the infant. 
The breast secretions are furnished during the time the infant's diges- 
tive apparatus is developing, and serve a purpose in addition to supply- 
ing nourishment. The secretions of the breasts adapt themselves 
to the increasing strength of the digestive organs, and, instead of these 
organs finding their work easier as they become stronger, they find 
the digestive work increases as their digestive capacity becomes 
greater. This is brought about by an alteration in the physical 
properties of the mother's milk in the stomach by the infant's gastric 
secretions before true digestion commences. The rennin, pepsin 
and acid of the stomach, as they successively appear, produce pro- 
found changes in the physical condition of the milk. When rennin 
acts alone, as it does in very early infancy, the milk becomes a fluid 
jelly; but later on when pepsin and acid appear the milk is changed 
into a mass having much of the consistency of well-chewed food, and 
which should be looked upon as its prototype. It is thus that the 
digestive organs are prepared to digest semisolid food about the 
twelfth month, when weaning naturally takes place. In addition 
to this interesting and important property of the mother's milk, it 
generally contains the food elements in the proportions and forms 
best suited for proper nutrition of the infant. 

It is not a difficult matter to bring together the food elements in 
the same quantities as are found in any specimen of breast milk, or 
colostrum, but even when derived from milk of lower animals the 
food does not have the delicate properties of the breast secretions, and 
it is often contaminated or has undergone bacterial changes. 

While many infants are successfully fed on substitutes for breast 
secretions, such feeding should not be attempted until every effort 
to secure breast-feeding has failed. An infant that is fed artificially 
is in reality a premature infant, for breast-feeding belongs in the same 
category as maternal feeding through the placenta. 

The death rate is much higher among artificially fed infants than 

119 



120 DISEASES OF CHILDREN. 

among those breast-fed, and in hot weather when bacterial changes 
in the food are greatest the loss of artificially fed infants is several 
times greater than during the colder seasons, while the increase in 
death rate among breast-fed infants is slight. 

Every consideration shows the advantage of employing the 
maternal method of nutrition while the infant's digestive organs are 
developing, and breast-feeding should always be advocated unless 
contraindicated (see p. 128). 

Preparation for Maternal Feeding.^For some months before 
delivery, the nipples should be treated so as to toughen them and thus 
prevent tenderness or fissure when the infant uses them. This is 
done by gently rubbing them between the thumb and fingers. De- 
pressed or misshaped nipples may thus be made usable, and the 
comfort of the mother will also be conserved. 

Management of Breast-feeding. — When the mother is enough 
rested after delivery the infant should be offered each nipple. If it 
does not seem satisfied and becomes fretful or restless, a teaspoonful 
or two of boiled water may be given. This will quiet the infant and 
helps to flush out the digestive tract and kidneys. 

For the first day or two the infant may be offered the breast 
every three hours during the day and twice during the night, at 
four- to six-hour intervals. After this it should be nursed every two 
hours during the day and once or twice at night. 

When the supply of milk is sufficient the infant will suck for 
fifteen to twenty minutes and then drop off to sleep. If after having 
the nipple twenty to thirty minutes the infant seems restless and 
unsatisfied it may be concluded that the milk supply is insufficient. 
A weighing before and after nursing may also help to determine 
whether the amount has been sufficient. After the first few weeks 
such a test should show an increase in weight of between two and 
three ounces. 

• If under such management the infant has soft yellow stools with 
no pronounced signs of indigestion and gains steadily in weight, it may 
be considered as doing well and requires no further attention. 

Regularity of Feeding Important. — One of the most fruitful causes 
of indigestion in breast-fed infants is feeding at irregular, and especially 
at short intervals. Sometimes a fresh feeding is taken into the stomach 
before the previous meal has been digested which is bad enough; 
but in addition to this, the irregularity in nursing has a profound effect 
on the composition of the mother's milk. 

If the intervals between nursings are long there will be a large 
quantity of rather poor milk; but when the milk is drawn at short 



BREAST-FEEDING. 121 

intervals it has the effect of reducing the quantity and greatly in- 
creasing the percentage of fat, the other ingredients not being affected 
to any great extent. An excess of fat in the food is apt to produce 
vomiting, and an abnormal gastric secretion may follow, causing the 
milk to curd or soHdify abnormally; hence it is not difficult to see 
why frequent nursing causes digestive disturbance. When milk is 
drawn at regular intervals it has practically the same composition, 
unless the mother has been subjected to influences that derange her 
nervous system. These may profoundly alter the character and com- 
position of her milk and produce great disturbances in the infant. 
It is, therefore, of the greatest importance to have the mother 
regular in her own habits and free from excitement, and that the infant 
be fed at regular hours. It will be helpful if the mother is given direc- 
tions for feeding by the clock, as at 5, 7, 9, 11 A. M.; 1, 3, 5, 7, 9 P. M., 
and once during the night in occasional cases. 

Milk Agrees, Flow Scanty. — When the mother's milk agrees with 
the infant, but is not sufficient in quantity to cause it to gain in 
weight steadily, attempts should be made to increase the flow, and 
when these are not successful, mixed feeding, that is, part breast 
and part artificial feeding must be employed. 

If the mother is to secrete sufficient milk she must digest and 
assimilate a liberal supply of food herself, for unless she does this the 
milk will be produced from her own tissues and she will lose in weight. 
The diet of the mother should consist of simple, easily digested food 
in hberal quantity, milk, eggs, and thoroughly cooked cereals being 
the mainstay. Tea and coffee should be withheld or used sparingly, 
cocoa or chocolate being given in their place. 

Southworth, who has devoted much attention to this matter, 
recommends the use of cornmeal gruels to be taken between meals as a 
means of increasing and conserving a scanty flow of breast milk. 
When cornmeal gruel is not relished, oatmeal gruel may be substituted. 
The gruels are n\ade as follows: 

Two to four heaping tablespoonfuls of yellow cornmeal or rolled oats are 
placed in one quart of cold water in a double boiler and the water in the boiler 
is kept boiling for two or three hours. The gruel is then strained through a 
coarse wire strainer and enough boiling water is added to make one quart of 
gruel. The gruel should be well salted. It is often advantageous to add an 
equal quantity of milk. 

A pint of such gruel is to be taken about ten o'clock in the morn- 
ing and again at about three in the afternoon. The gruel, when dex- 
trinized, supplies energy food in a form quickly assimilable, and the 
coarse particles of the gruel undoubtedly promote normal action of 



122 DISEASES OF CHILDREN. 

the bowels and thus promote the general well-being of the mother and 
incidentally that of the infant. When there is anemia iron should be 
administered. 

Elimination of Drugs and Excretory Products in Milk. — It is a 
well-known fact that some substances pass into the milk from the 
mother's system which may unfavorably affect the infant. Consti- 
pation of the mother will affect the infant unfavorably, and under cer- 
tain conditions urea in appreciable quantities finds its way into the milk. 
When the mother is constipated and the use of cornmeal gruel does not 
overcome the condition, cascara should be given. 

Great care must be exercised in giving drugs to nursing women, 
as they may be excreted in their milk. Morphin, mercury, quinin, 
iodid of potassium and similar preparations should be given cauti- 
ously and their effects watched. 

Milk Plentiful, but Disagrees with Infant. — As a general rule, the 
milk of the mother will agree with her infant. However, there are 
some women whose milk may at times be excessively rich in all of 
its elements or which may fluctuate widely in the amount of fat 
present or have properties that make it unacceptable to the infant. 

If the milk agrees with the infant for a time and then suddenly 
disagrees the probabilities are that the mother has been subjected to 
excitement of some kind; it may be worry, fright, anger, grief, or loss 
of sleep that has made her irritable. Such influences will produce 
sudden changes in the character of milk and alter its digestive proper- 
ties. It is well known that the milk of a cow that has been overheated, 
driven rapidly, or made irritable by flies or dogs will not react nor- 
mally to rennin and acid. The changes brought about by these 
nervous influences are more than variation in percentage composi- 
tion, and cannot be detected by chemical analysis. The remedy 
in this class of cases is to remove all causes of anxiety and nervous 
disturbance, and have the mother sleep in another room so that she 
shall not be disturbed by the infant's crying. Pleasant surroundings, 
and moderate daily exercise in the fresh air are also indicated. 

Sometimes the milk of one breast is perfectly satisfactory while 
that of the other causes disturbance. In such cases the remedy is to 
secure all of the feedings from the good breast if possible until the 
other one secretes normal milk. 

When the milk disagrees from the start and the mother seems 
healthy it is possible that the trouble is caused by the milk being too 
rich, the result of overeating on the part of the mother. At any rate 
it is helpful in all of these cases where the milk disagrees to make an 
examination of it, as will be explained in the next paragraph. 



BREAST-FEEDIXG. 123 

If it is found that the amount of fat and total solids in the milk 
is too high the diet of the mother should be restricted, and exercise 
to the point of fatigue, to divert the food supply from the breasts, may 
be advised. It may also be necessary to give saline cathartics. If 
there is an over-abundant supply of rich milk, the infant should be al- 
lowed to take only the first milk from each breast and thus avoid the 
extra fat '^strippings" or the last milk secreted which contains a much 
higher percentage of fat than the first part of the secretion. If the 
infant has curdy stools and colic, a tablespoonful of barley water, lime- 
water, or water containing one grain sodium citrate may be given just 
before each nursing. 

If the methods of management suggested above do not overcome 
the difficulty, so that the infant gains from four to six ounces a week, 
with good digestion and normal stools, it will be necessary to resort to 
mixed feeding. Give a bottle every other feeding, using a formula suit- 
able for a younger infant at the beginning, as described on page 168- 

Examination of Breast-milk. — There are three ways of examining 
breast milk: (1) by having an analysis made showing its percentage 
composition expressed in proteins, mineral matter, fats, carbohydrates, 
and water; (2) by roughly determining these ingredients by means of 
the amount of cream that will rise on a given quantity of milk and the 
specific gravity of the milk; (3) by the use of the pioscope. 

The chemical analysis of milk is expensive, and its value is apt to 
be overestimated. It takes several days to get a report from the 
laboratory where it is made, and laboratories for this purpose are not 
always available. The second method of determining fats and 
specific gravity takes twenty-four hours, but can be utilized anywhere. 
A specimen of the milk is drawn from the breast, care being taken to 
get all there is, because the first portion contains little fat, while the 
last portion or ''strippings" is very rich in fat. The milk is mixed 
and its specific gravity is taken wdth an ordinary urinometer. Ten 
cubic centimeters of the milk are then placed in a graduated ten c.c. 
tube or graduate and allowed to stand twenty-four hours for the 
cream to rise. Poor milk will have a small layer of cream and rich 
milk a much thicker cream layer. The amount of fat in the milk is 
thus estimated. The specific gravity of normal human milk is about 
1.031. If the milk shows a layer of cream not over one c.c, and has 
this specific gravity, it may be looked upon as normal milk as far as 
percentage composition is concerned. If the specific gravity should be 
as low as 1.028, with more cream, it would indicate that the milk was 
rich in fat, as the fat being lighter than the milk serum reduces the 
specific gravity of the milk. 



124 DISEASES OF CHILDREN. 

This method is widely used in the dairy industry for calculating 
the composition of cow's milk, but the fat is accurately determined 
by the Babcock test (page 190), which may also be used with human 
milk. About half an ounce of milk is required for this test, but if 
this quantity cannot be obtained^ what is available may be diluted 
with water two or three times after the specific gravity has been 
obtained and the result multiplied by the number of times the milk 
was diluted. 

If the specific gravity is above 1.03 and there is little cream, 
or fat shown by the Babcock test, the milk is poor in fat and normal 
in other solids, or all of the milk was not drawn from the breast and 
the portion containing the fat was left behind. A second specimen 
should be drawn and greater care taken to get all there is. The milk 
should be drawn at the regular nursing interval or milk extra rich in 
fat will be obtained, for, as stated before, milk drawn at short intervals 
is abnormally rich in fat. « 

At one time great importance was laid upon the reaction of 
breast milk. It was supposed always to be alkaline or amphoteric 
in reaction. At present comparatively little importance is attached 
to the reaction of breast milk, for the same specimen of milk may be 
found to be acid, amphoteric, and alkaline, all depending upon how 
the reaction is determined. Litmus-paper was the substance used 
to determine the reaction of milk, a strip being dipped into the milk 
and its reaction judged by the change of color of the litmus-paper. 
Litmus and litmus-paper vary a great deal in sensitiveness, and all 
kinds of reactions can be obtained with milk by using different lots 
of litmus-paper. Phenolphthalein in 1 per cent, 
alcoholic solution is now used as the indicator 
in testing the reaction of both human and cow's 
milk, as it is many times more sensitive than 
litmus. Lime-water is usually employed in 
neutralizing acidity in milk, and it takes about 
10 per cent, to 20 per cent, to make human 
milk alkaline to phenolphthalein. With a 
better understanding of the chemistry of milk Fig. 33.— Pioscope 
and the process of its digestion, it is seen that 

undue importance was placed upon its reaction and composition, and 
simpler and better methods of clinically testing the suitability of 
breast milk are coming more into use. 

Fig. 33 is an illustration of the pioscope which is used for testing 
breast milk. It consists of two disks, one of hard rubber and the other 
of glass, which rests upon the rubber disk. The glass disk is divided 




BREAST-FEEDING. 



125 



into sectors which are colored to represent milk of different qualities. 
The milk is drawn from the breast and a few drops are placed in a little 
depression in the rubber disk. The glass disk is then placed on the 
rubber one and the milk is compared with the different sectors of the 
glass disk. At a glance one can tell approximately the quality of the 
milk. The apparatus is about one-fourth of an inch thick and can be 
easily carried by the physician. Its great advantage lies in the fact 
that it enables the physician to know at once what the conditions he 
has to deal with are, and it requires no skill in using. The following 
case illustrates its usefulness-. An infant which was being breast fed 





Fig. 34. — Breast 
pump. 



Fig. 35. — Hoover 
breast pump. 



and had previously been doing well suddenly suffered with digestive 
disturbance. The milk of each breast was tested with the pioscope, 
and it was found that the milk from one breast corresponded with 
''normal" on the pioscope, while that of the other breast did not. 
Directions were given to nurse from the normal breast and the infant 
had no further trouble. The difference in the milk was discernible by 
the eye. If the milk of both breasts had been mixed and analyzed, 
or its composition estimated from its specific gravity and cream layer, 
the fact that the milk of one breast was different from that of the 
other in all probabihty would not have been known, and the treatment 
might have been to stop breast-feecUng and try artificial feeding, which 
as it proved was unnecessary. 



126 DISEASES OF CHILDREN. 

Nursing not Possible. — When the nipples are fissured it is impos- 
sible for the infant to nurse, and the milk should be drawn with a 
breast pump, two forms of which are shown in Figs. 34, 35. The 
Hoover breast pump (Fig. 35) will be found convenient and easy 
to use. Heating an empty bottle and placing the neck over the nipple 
will sometimes prove satisfactory in collecting milk. The milk may be 
fed through a medicine dropper or from a small nursing bottle. Pumps 
and bottle should be kept scrupulously clean. 

When there is but a slight fissure or abrasion which causes pain 
to the mother, a nipple shield (Fig. 36) may be used. It is best 
to fill it with warm water so that the infants will not have to exhaust 
the air it contains before obtaining any fluid. It 
is also well to massage the breasts to aid in secur- 
ing the milk. The nipples should be carefully 
washed with a solution of boric acid and dried 
after use. 

Contraindications for Nursing. — When the 
mother is anemic and is losing weight and shows 
signs of exhaustion, even after tonic treatment has 
been employed; or when she is nervous and excit- 
able to such an extent that her milk continually 

disagrees with the infant, breast-feeding should be ^^'^ 36 —Nipple 
1- • 1 T-r- 1 • • shield, 

discontmued. If when menstruation is resumed 

the milk disagrees, artificial feeding may be employed temporarily, 
and after the period has passed breast-feeding may be commenced. 
In the meantime the breast should be emptied with a breast pump 
at regular intervals to keep up the secretion. If the milk disagrees 
but slightly it may not be necessary to feed artificially. 

If pregnancy occurs it may be necessary to employ substitute 
feedings, but in the middle of a hot summer it will be better to con- 
tinue the breast-feeding, if it is not too much of a strain on the mother, 
than to risk the dangers of commencing artificial feeding in hot 
weather. Mothers affected with tuberculosis should under no cir- 
cumstances be permitted to nurse their infants. Diseases such as 
typhoid, pneumonia, and septicemia in which there is much pyrexia 
and prostration also are contraindications to nursing. 

Weaning and Mixed Feeding. — Whenever the mother's milk fails 
in quantity or quality, it becomes necessary to commence substitute 
feeding to make up the deficiency. It is a good plan to have one bottle 
a day given to a nursing infant about the third month so it shall be 
trained to its use and the mother trained in the preparation of food. 
This will be much appreciated in cases where sudden weaning becomes 




BREAST-FEEDING. 127 

necessary. The substitute feeding may alternate with breast-feedings, 
and as the breast secretion fails the number of bottles given may be 
increased one at a time. In this way the transition is gradual and 
digestive disturbances are avoided. During the first few weeks of 
life, when the nursing mother has little milk, a small amount may be 
given from the bottle immediately after nursing if the infant gets too 
little from the breast. 




Fig. 37.— Preferable type of breasts for wet-nursing. 

Whenever sudden weaning becomes necessary a wet-nurse should 
be employed if possible, as no substitute feeding can compare with 
good wet-nursing. 

Selection of a Wet-nurse. — In selecting a wet-nurse, we must 
consider her age, her general health and development, her probable 
nervous status, and the age and health of her infant. The preferable 
age for the nurse is between twenty and thirty years, and mult ip arse 



128 DISEASES OF CHILDREN. 

are apt to do better than primiparae on account of having had charge 
of the suckHng and general care of infants. A careful physical 
examination of the applicant should be made by the physician. 
Constitutional taints, especially syphilis and tuberculosis, must be 
excluded by a painstaking history and thorough examination of the 
mouth, lymph-glands, skin, and other parts likely to show evidences 
of infection. If any vaginal discharge is present, it must be ex- 
amined for gonococci. The best breasts for satisfactory suckling 
are not the large, firm ones, but rather the more flabby and pendu- 
lous kind, as shown in Fig. 37. The nipple must be of good form 
and size and sufficiently protuberent for easy grasping by the infant, 
and free from fissures and abrasions. A woman of quiet, phleg- 
matic temperament, in good health, is to be preferred, as nervous 
instability has a quick effect on the composition of the milk. A 
woman whose infant is under six months, can usually suckle a new- 
born baby, but a less disparity between the ages of the infants is 
desirable if it can be attained. A careful examination of the nurse's 
infant must be made to exclude any constitutional disease, especially 
syphilis. Such examination will also show how well the infant has 
thriven upon its mother's milk. ' The diet of the wet-nurse, when se- 
lected, should be as nearly as possible that to which she has been accus- 
tomed, avoiding a too great variety and quantity of food. If she is 
furnished a diet richer and more abundant than she is accustomed 
to, she will in all probability overeat and bring on either defective 
digestion or excretion, which will promptly disorder the digestion of the 
infant. Regular outdoor exercise must also be insisted upon. Several 
nurses will sometimes have to be tried before a breast that agrees with 
the baby is found. 



CHAPTER XIII. 
THE PRINCIPLES OF SUBSTITUTE FEEDING. 

Difficulties Encountered. — In attempting to feed infants artificially, 
one of the first impressions received is that the whole subject is chaotic. 
Methods that give brilliant results in some instances totally fail in 
other cases apparently the same. One infant will thrive on a quantity 
of food that is insufficient for another of the same age; another may 
gain in weight rapidly and still not be rugged and Avell-developed. 
The parents may be poor, ignorant, or careless, and great difficulty may 
be experienced in getting a supply of suitable food, or in having the 
food prepared and administered properly. Learning the formulas of 
a few food mixtures will never make a good or successful infant feeder. 
What is required is a clear conception of what are the essential prin- 
ciples involved in artificial infant-feeding in health and disease, and a 
working knoAvledge of how to prepare food so that these principles 
may be complied with under different conditions. 

Principles that Apply to all Infants. — All infants require a certain 
quantity of proteins and mineral matter to replace normal metabolic 
waste, and enough fats and carbohydrates to supply the energy needed 
to carry on the processes of Hfe. A food that supplies exactly these 
quantities of the food elements is called a maintenance ration, and on 
such a food the infant w^ould neither gain nor lose. Oftentimes in 
cases of illness it becomes necessary to put infants on such food, and 
the parents may feel the infants are being starved, but they are not on 
a starvation diet by any means; growth is suspended temporarily, but 
the infant is holding its own. 

After the portion of the food needed for maintenance has been ap- 
propriated, what remains, if any, may be utilized for growth or for 
causing gain in weight which does not necessarily mean that the infant 
is really growing. Growth consists in an increase in number of the 
cells of the various tissues, and as these are composed principally of 
proteins and water the food must contain a greater quantity of 
proteins than is required to replace waste, if growth is to be made 
possible, for cells cannot be formed from fats and carbohydrates. A 
rapid gain in weight may result if the food given contains only a little 
more protein than is necessary to replace waste, but considerable 
9 129 



130 DISEASES OF CHILDREN. 

fat and carbohydrates, as the excess of these ingredients is con- 
verted into body fat which causes increase in weight. To those not 
famiHar with the principles of infant-feeding this gain in weight is 
strong evidence that the food is suitable for the infant, but not so 
much importance is attached to mere gain in weight as formerly. If 
the food is known to contain a liberal supply of proteins, and gain in 
weight follows its* use, it is considered that the gain in weight is caused 
by true growth, as it is characteristic of young animals of all kinds to 
greedily assimilate and convert into tissues the proteins that the food 
contains in excess of that needed to replace waste, within reasonable 
limits. Proper growth hinges on the proteins of the food. 

If the food contains a relatively large proportion of proteins 
with a too small proportion of fats and carbohydrates the proteins 
will be used to supply energy which could just as well be furnished 
by fats and carbohydrates, and growth will not take place. If the 
quantity of fats and carbohydrates is increased and the amount of 
proteins decreased somewhat the infant will be able to make a satis- 
factory growth, therefore it is important to have the food elements 
present in the food in certain relative proportions if best results are 
to be obtained. 

It is possible to profoundly alter the character of the body by 
modifications of the diet during the early growing period. Much 
scientific work has been done along this line at the Agricultural 
Experiment Stations of the various States in the efforts to learn the 
principles involved in the production of meat for market, and how to 
select food so as to produce the most rugged animals. It was found 
that a liberal supply of protein in the early stages of growth produced 
larger animals, made their vital organs larger, gave them more blood, 
stronger bones, and about one-third more muscle than food poor in 
proteins, but rich in fats and carbohydrates. 

The essentials of artificial infant feeding are: a liberal supply of 
proteins and mineral matter for the construction of additional tissue, 
which means growth; a sufficient supply of fats and carbohydrates to 
furnish energy, and all in forms that can be not only digested by the 
infant, but which permit the development of vigorous digestive 
organs. A strong digestive apparatus is of great importance in after- 
life, and by proper selection of food in infancy the foundation for good 
digestion later on can be laid. 

Many Forms of Proteins, Fats, and Carbohydrates Used in Feeding 
Infants. — Proteins for infants are obtained in cow's or goat's milk, 
from cereals, and from eggs, and in a few instances in the form of meat 
broths and meat juice. The cereals should be looked upon as vege- 



THE PRIXCIPLES OF SUBSTITUTE FEEDIXG. 



131 



table eggs, as they are composed of the embryo plant and enough food 
to nourish its protoplasm with proteins and carbohydrates until its 
organs for securing food are developed. Mineral matter which is a 
mixture of many salts is obtained in milk and the cereals, in com- 
bination with the proteins presumably, for it is never supplied in a 
separate state. Fats are taken in the form of milk or cream almost 
exclusively. Carbohydrates are utilized in the form of milk-sugar, 
granulated sugar, maltose and dextrin derived from starch, and 
cooked starch. 



CHAPTER XIV3 
MATERIALS USED IN SUBSTITUTE FEEDING. 

Cow»s Milk. 

General Composition. — Chemical analysis shows the milk of all 
cows to be composed of proteins, mineral matter, fats, carbohydrates, 
and water, but the proportions of these ingredients are not the same 
in all specimens of milk from the same cow or from the cows of dif- 
ferent breeds. The composition of milk depends largely on the breed 
of cow, the individual peculiarities of each cow, and the time and 
manner of milking. 

One Cow's Milk. — It was formerly believed that the milk of one 
cow was preferable to the mixed milk of a herd of cows for use in infant- 
feeding, but as improved and more sanitary methods of handling herd 
milk have done away with much of the contamination which brought 
such milk into disrepute, it is now much better to use the mixed milk 
of a large number of cows, especially as it is more uniform in 
composition and less liable to sudden fluctuations and changes of 
properties. 

The range of composition of the milk of single cows has been 
found to be from 2.25 per cent, to 9 per cent, of fat, and 2.19 per cent, 
to 8.56 per cent, proteins (Van Slyke), while in mixed herd milk 
there is seldom much of a range of variation, the fats running almost 
never below 3 per cent, and very seldom over 5 per cent., except in 
the milk of high-bred Guernsey and Jersey cows; while the proteins 
will almost always run between 3 per cent, and 3.5 per cent. 

If a cow is affected with tuberculosis the danger of infecting the 
infant is much greater than if her milk is diluted by the milk of other 
cows which are free from tuberculous infection. Again, the com- 
position and properties of a cow's milk are seriously affected by fright, 
worry, teasing by a dog, or the annoyance of flies. The milk of a 
frightened cow has been known to kill her calf, so the use of one cow's 
milk is attended with greater risks than the milk of a herd of healthy 
cows that has been properly handled as it is not likely that all of the 
cows would be subjected to the same abnormal conditions. 

Influence of Breed on Composition of Milk.— The milk of different 
breeds of cows shows marked differences of composition and no 

132 



MATERIALS USED IX SUBSTITUTE FEEDING. 133 

amount of effort will make the cows of one breed give milk of the same 
character as the cows of another breed. Holstein cows will give milk 
containing about 3 per cent, fat^ 2.80 per cent, proteins, and 4 per cent, 
carbohydrates, while Jersey cows will give milk containing as high as 
5.5 per cent, fat, 3.60 per cent, proteins, and 5 per cent, carbohydrates. 
Other breeds give milks which fall between these two extremes, but 
it is seldom that milk of pure-bred cows is offered for sale unless it is 
from the dairy of some ''gentleman farmer" who is a cattle fancier. 

Bacteriology of Milk. — Milk as secreted by a healthy udder is 
practically sterile, but just inside the teat is a " milk cistern" to which 
bacteria from outside find access. For this reason the first three or 
four jets from each teat should be discarded and then the milk will 
be quite free from bacteria if received under proper conditions into 
sterile pails. But owing to the small profit or possibly no profit at 
all that comes to the milk producer, as most milk is sold at about the 
cost of production, he cannot take proper care of his cows or the 
utensils employed, and the milk becomes highly infected at times 
with all kinds of bacteria, some of them pathogenic. A visit to one 
of the barns in which cows were kept for the production of milk for 
market a few years ago would have shown a dark, poorly ventilated 
building, the beams covered with dust and cobwebs, the bodies of the 
cows plastered over with manure, and piles of loose hay and manure 
lying near the cows while the milking was being done. Milk from 
such dairies would contain hundreds of millions of bacteria to the 
cubic centimeter, but fortunately most of these bacteria were sapro- 
phytes, and the harm they did was chiefly in souring the milk by 
converting its sugar into lactic acid or decomposing the proteins. In 
hot weather the heat would favor development of new bacteria and 
the milk would not keep. This led to a demand for sterilization or 
pasteurization, but it has since been found that it is much better to 
produce milk under sanitary conditions and thus keep down the 
number of bacteria than to kill them by heat after they have been 
allowed to get into the milk and attack it. 

Another thing that would have been noticed at this dairy, possibly, 
is that the milkers did not wash their hands or wear clean clothes, and 
that the water used in washing milk pails and cans came from a well 
close to a water-closet. If there was an infectious disease, such as 
scarlet fever or typhoid fever in the family of any of those who handled 
the milk, the opportunity for infecting the milk was present, and 
there are many recorded instances where epidemics of typhoid fever 
particularly have been caused by milk infected by those handhng the 
milk or bv water used in washing utensils. 



134 DISEASES OF CHILDREN. 

Fortunately, this state of affairs is not as common as formerly, 
and the physician to-day does not have the problems to contend with 
in obtaining a good supply of milk that the physician of ten years ago 
had to deal with. The principles involved in the production of whole- 
some milk are now well understood, and are being applied more and 
more even in remote parts of the country, and good milk suitable for 
feeding infants can be produced anywhere by the exercise of care and 
cleanliness. 

Production of Sanitary Milk. — All that is needed to produce milk 
suitable for feeding infants are cows that are free from tuberculosis 
or other disease, a stable that can be kept clean — an ordinary barn will 
do — and careful attention to keeping the cows and utensils clean. 
The cows are to be cleaned daily and kept as sleek and clean as 
horses. The hair on the udder is to be kept cut short and the udder 
and belly are to be wiped off with a damp cloth just before milking. 
No loose hay or manure is to be left in the stable when milking is 
going on, as dust from them carries bacteria with it into the milk. 
All utensils are to be washed with boiling water, and steamed if 
possible. The milker should wear clean clothes, and his hands should 
be washed with soap and water just before milking. The first few 
streams of milk from each teat should be thrown away, not into the 
milk pail, but into the manure gutter, and the milking should then 
proceed into a small mouth pail. The milk should then be strained 
through a sterile cloth and cooled and iced and kept iced until ready 
for consumption. 

The bacterial condition of milk is of as much importance as its 
chemical composition and should never be left out of consideration. 
It is well also to remember that methods of milk production in America 
and Europe are totally different, and that European literature on this 
subject does not always apply to American conditions. 

Market Milk. — From a commercial standpoint milk may be 
divided into three grades: (1) "Grocery milk, "such as is sold at very 
low prices in city grocery stores, especially in the tenement districts, 
and dipped out of cans into the family pitcher; (2) bottled milk, such 
as is delivered to families in glass bottles in the more well-to-do 
sections; (3) sanitary, inspected, or certified milk, which is also sold 
in bottles. 

Grocery milk is produced at as low a cost as possible and con- 
tains enormous numbers of bacteria, as no more care is taken in its 
production than the health authorities insist upon. It is a poor food 
for infants, especially in hot weather, when it may be positively 
dangerous. 



MATERIALS USED IX SUBSTITUTE FEEDING. 135 

Bottled milk is generally produced under much better conditions 
than grocery milk and sells for about double the price of the grocery 
milk. It forms a satisfactory milk for infant feeding in a large number 
of instances. 

Sanitary, inspected, or certified milk is produced under the super- 
vision of a commission of physicians, usually appointed by a local 
medical society. Such commissions furnish standards of cleanliness 
and bacterial count which are to be complied with. Then if the milk 
when taken at random from the milkman's delivery wagon comes up 
to the standard, he is furnished with a label certifying that the milk is 
of the required quality, or ^'certified milk," as it is often called. The 
standards fixed by ''milk commissions" in different cities are not all 
alike. In Philadelphia, for instance, the number of bacteria per cubic 
centimeter must not exceed ten thousand, while in New York the 
maximum number must be not over thirty thousand per cubic centi- 
meter. Certified milk is the safest and best milk obtainable for use in 
infant feeding, and can now be had in most large cities and in some 
small ones. There is no reason why it should not be obtainable any- 
where. Any progressive dairyman or farmer can produce it. The 
price of this milk is 50 to 100 per cent, higher than that of ordinary 
bottled milk. 

It is important that the certification be done by some competent 
medical authority and no milkman should be allowed to do his own 
certifying. 

Pasteurized and Sterilized Milk. — By heating the milk to about 
160^ F. for about twenty minutes the great majority of bacteria pres- 
ent are destroyed. Such treatment of milk is called pasteurization. 
If the milk is heated to 212° F. it is said to be sterilized, as all of the 
bacteria are destroj^ed. In both of these processes the bacterial spores 
survive, and if the milk is not kept below 50° F. they will germinate, 
and soon the milk will contain as many bacteria as it did originally, 
but the tj'pe or kind of bacteria will not be the same. Bacteria that 
convert the sugar of milk into acid and cause souring are the pre- 
dominating kinds in fresh milk and the acid they produce retards 
the growth of other types, until, when milk is nearly soured, 95 per 
cent, of all the bacteria present are acid producers. Heating the 
milk to above 150° F. destroys the acid bacteria and leaves a free 
field for bacteria that attack proteins. Therefore pasteurized or 
sterilized milk does not readily sour, but its proteins are often partially 
decomposed by bacteria produced from spores which escaped der 
struction, and such milk may cause considerable digestive disturbance. 
Pasteurization or sterilization may be used to take the place of clean- 



136 DISEASES OF CHILDREN. 

liness in producing milk, but it is not to be advocated for this purpose. 
If the milk is suspected of conveying pathogenic bacteria, then it should 
be pasteurized, but this should be done if possible in the home when 
the infant's food is prepared, so that there shall be no opportunity 
for contamination between the time the milk is pasteurized and the 
infant receives its food, for pasteurized milk is just as liable to be un- 
healthful as fresh milk if it is not protected from reinfection. Ster- 
ilized milk is not used to any great extent because it has a cooked taste. 
Pasteurized milk tastes very much as fresh milk does, although a differ- 
ence is discernible. Heating milk in some way alters it so that it is 
not solidified by rennin as quickly as fresh milk, and this property is 
often taken advantage of in preparing food for infants in whose 
stomachs fresh milk solidifies too rapidly. Heating the food may 
make it digest satisfactorily. 

Composition of Market Milk. — Nearly all of the States have laws 
regarding the composition of milk and cream. Most of them require 
the milk to contain 12 per cent, of total solids, of which at least one- 
fourth must be fat. A few States require the milk to contain 3.5 per 
cent, fat, and solids not fat 9 per cent, or slightly more. 

Since the introduction of bottled milk the public has become edu- 
cated to look for a layer of cream in the necks of the milk bottles. 
Milk containing but 3 per cent, of fat will not produce a satisfactory 
layer of cream, so either cream is added to milk containing but 3 per 
cent, fat, or the cream is allowed to rise on such milk, and a portion 
of the milk under the cream is drawn off thus increasing the percentage 
of fat in what remains. Milk for the general bottled trade will contain 
between 3.5 per cent, and 4 per cent, of fat, about 3.20 per cent, 
proteins, and 5 per cent, sugar and mineral matter. Some milk 
dealers with poor facilities will bottle 3 per cent, fat milk, but it 
will not pass with most purchasers of bottled milk. Bottled milk 
from fancy Jersey cattle will contain from 4.5 per cent, to 5.5 per cent, 
fat, 3.5 per cent, proteins, and 5 per cent, sugar and mineral matter. 
Certified milk generally contains 4 to 5 per cent, of fat, with the other 
ingredients about the same as in good bottled milk. 

Cream. — There are two kinds of cream sold by milk dealers: 
(1) Gravity cream, or that which rises naturally if the milk is allowed 
to stand; (2) centrifugal cream, or that which is separated by passing 
the milk through a centrifuge running at a high rate of speed. The 
percentage of fat in cream varies, running all the way from 16 per cent, 
up to 40 per cent. Some gravity cream may run as low as 16 per cent, 
and as high as 25 per cent. Centrifugal cream can be made of any 
desired percentage of fat by adjusting the centrifuge. There are 



MATERIALS USED IX SUBSTITUTE FEEDING. 



137 



marked physical differences between gravity cream and centrifugal 
creams. Gravity cream will ''whip" much better than centrifugal 
cream., and for some purposes in catering centrifugal cream cannot be 
employed. Centrifugal cream is much thinner than gravity cream 




Fig. 38. — Microscopic appearance of normal milk {Babcock and Russell.) 
Fat globules in clusters. 




of the same composition. Heating or pasteurizing milk or cream 
produces much the same effect as centrifuging, and to overcome the 
effect of these processes there has been invented a method of restor 
ing the ''body" to such milk or cream, which consists in adding a 



138 



DISEASES OF CHILDREN. 



combination of calcium hydrate with cane-sugar, called syrup of lime 
or ^^viscogen." This substance will cause cream or milk to thicken 
perceptibly, and is sometimes used to make poor cream appear like 
richer cream. Figs. 38, 39 show the microscopic appearance of normal 
milk and milk that has been centrifuged or heated. 

Condensed Milk. — There are on 
the market, and widely used, a large 
number of brands of condensed milk. 
These are made by evaporating milk 
in vacuum pans, at a low tempera- 
ture, after it has been brought near 
the boiling-point. If it is to be sold 
in the fresh state it is then run into 
cans and shipped to market. Other- 
wise, granulated sugar is added and 
the milk is then put into small cans 
and hermetically sealed. Such milk 
is known as sweetened condensed 
milk. It is a one-sided diet contain- 
ing an excess of carbohydrates. It 
will make children very fat because 
they change its excess of sugar into 
body fat, but when it is diluted so 
they can digest it the percentage of 
proteins or blood and muscle-forming 
portion of the food is not much more 
than half that of mother's milk, and 
of course the infant cannot grow prop- 
erly on it. : There is also a great de- 
ficiency in fat. \ 

Evaporated' Milk.— There is also ^ig. 40. -Obesity with lack of 

- . proper musculature, resulting from 

sold m cans what used to be called high carbohydrates and low protein. 

*^ evaporated cream" but which 

since the passage of the "Pure Food and Drugs Act" in 1906 is 

called by its true name '^evaporated milk." This is condensed milk 

which has been canned without the addition of sugar. It has a 

creamy consistency and when diluted with water is very much like 

sterilized milk. It does not sour readily, but is liable to putrefaction, 

and for this reason is put up in small cans that shall be used up soon 

after opening. It will not keep when opened as will the regular 

condensed milk. 




MATERIALS USED IX SUBSTITUTE FEEDING. 



139 




Cereals. 

The various cereals play an important part in artificial infant- 
feeding, and when used intelligently are of greatest service. In 
feeding sick infants and for tiding over a period when milk is not 
tolerated; the cereals and products derived from them are the main 
reliance. But it should also be remembered that if used injudiciously 
they may cause considerable disturbance. 

General Properties of Cereals. — The cereals are essentially vege- 
table eggs. That is, they are composed of the plant germ and 
enough food to nourish this germ until it has developed organs for 

securing food from the soil and air. 
All cereals are composed of fats, car- 
bohydrates, proteins, and mineral 
matter in different proportions. The 
amount of fat in wheat flour is about 
1 per cent., while the quantity in oat- 
meal is about 9 per cent. Barley 
flour may contain as high as 3 per 
cent, fat, while pearl barley will con- 
tain as little as 0.7 per cent. fat. 
Proteins vary in much the same way. 
Barley flour may contain as high as 
13 per cent, and as low as 7 per cent, proteins. These differences 
are largely due to the methods of preparing the cereals for use. 
Fig. 41 is an illustration of a cross section of a cereal in which 
it will be noticed that the proteins are found in the outer layers of 
the grain. In making pearl barlej^ the outer layers are ground off, 
leaving the interior portion which contains a relatively high pro- 
portion of carbohydrates or starch. Accordingly, a sample of barley 
may contain 13 per cent, proteins and 74 per cent, carbohydrates, 
and after it has been ''pearled" it will contain 7 per cent, proteins and 
77 per cent, carbohydrates. The proteins of barley make an exceed- 
ingly sticky dough when the flour is mixed with water, and for this 
reason it is desirable to remove a portion of the protein for certain 
purposes in cooking and some flour is made from barley from which 
the protein layer has been removed. Such flour stirs into water 
very easily and for cooking purposes is very convenient. From a 
nutritive standpoint such flour is not the best, as in infant-feeding 
particularly, the main object is to give as much proteins as can be 
utilized, and cereals containing the full quantity of protein are to be 
preferred. 



Fig. 41. — Barley grain. (Goodale.) 
c, Protein layer; d, starchy portion. 



140 ' DISEASES OF CHILDREN. 

Carbohydrates of Cereals. — The skeleton and tissues of plants are 
composed of carbohydrates, while in animals the tissues are mostly 
proteins. Naturally, then, the cereals are composed largely of car- 
bohydrates, the proteins which are only necessary for the formation 
of new protoplasm being present in smaller amounts. The carbo- 
hydrates may be in a number of forms, and the plant and its germ has 
the power to change one form into another as is needed. For for- 
mation of plant tissues they may be changed into cellulose, of which 
cotton is a good example. For storage of a reserve supply they may be 
changed into starch or inulin. When the reserve or starch is drawn 
upon, the plant secretes enzymes which change the starch into a 
soluble form. The starch first becomes soluble, it is then changed 
into dextrin and finally into maltose. These changes can readily be 
brought about in preparing food for infants, and this fact is of impor- 
tance, for oftentimes carbohydrates in the form of starch will not be 
acceptable, when by being converted into soluble starch, dextrin, 
or maltose they will not only be well digested, but will bring about a 
marked improvement in general conditions. Many of the proprietary 
infant foods are made in whole or in part of cereals which have been 
treated so as to affect the properties of their carbohydrates, or starch. 
The amount of cellulose in cereals is very small. Details for pre- 
paring cereals for infants will be found at page 170. 



Eggs. 

Eggs. — These are to the animal kingdom what the cereals are to 
the vegetable kingdom^a germ with material which it can use in form- 
ing an animal organism which is capable of digesting food from other 
sources. As the animal tissues are almost entirely made up of pro- 
teins and water, eggs naturally are likewise composed principally of 
proteins and water. They also contain fat, and lecithin from which 
nerve tissue may be formed, and organic iron for blood formation. 
Eggs of different animals vary in composition according to the devel- 
opment of the young when hatching takes place. Hen's eggs are the 
ones principally used and these contain enough of the food elements 
in suitable form to make all kinds of tissues, as the chick comes out 
of the egg fully formed, and its growth then consists almost entirely 
of enlargement. 

Eggs, therefore, are very useful additions to diet during the 
growing period, and especially when the infant is beginning to eat table 
food and needs easily digested proteins. 



I 



MATERIALS USED IN SUBSTITUTE FEEDING. 141 

Proprietary Infant Foods. 

General Properties. — Before the subject of infant-feeding was as 
well understood as it is at present, many attempts were made to fur- 
nish artificial foods which should take the place of mother's milk and 
of cow's milk. For a time they served a useful purpose and when it 
was impossible to obtain a supply of good cow's milk they were of 
considerable value, as very often they were retained and saved the 
infants from starvation or serious digestive disturbance caused by 
contaminated milk. On them many infants gained in weight and 
thrived temporarily, but frequently these infants developed rickets 
and scurvy, or were poorly developed and of feeble constitution, and 
consequently were carried off by the first serious sickness. All of 
these foods are composed of proteins, mineral matter, fats, and car- 
bohydrates. In some the amount of fat is infinitesimal, the protein 
low in quantity and the carbohydrates very high. None of them are 
at all like mother's milk in properties. They often contain only 
enough protein to but little more than make up for metabolic waste, 
but the carbohydrates are in such a form that they are easily assimi- 
lated and converted into fat which causes increase in weight. 

All of the proprietary infant foods are composed of cereals, sugars, 
dried milk, and eggs, either singly or in combinations that haA^e under- 
gone special treatments. Chemical analyses show little or none of their 
properties except their possible nutritive value. The most recent 
analyses available are given on page 142 "and are taken from the 1908 
report of the Connecticut Agricultural Experiment Station. 

Classification of Proprietary Infant Foods. — A clear idea of what 
the infant foods on the market are like will be obtained if they are 
classified according to the materials from which they are made, and 
according to this plan they will all fall into about three or possibly 
four distinct groups or classes, as follows: 



03 




s 




ti 


CD 


^ 






d 


X 


;-( 


0) 


TI 


73 


>. 




X, 


?-i 


n 


Cj^ 


bf 


^H 


:3 


c3 


cw 


o 


^ 


C 










a 


bf) 


^ 


4:: 


rr 


xs 


■^ 


fl 


C 


a1 


3 
O 


M 


a 








<D 


a 


Ef 


^ 


03 


n 






r^ 





-M 


Ui 


^ 


rn 


CTJ 


o 
















ft 




'cS 


^ 


a 


n 




^ 


^fl 


m 


^ 




a 


ti 


r/j 




> 


CD 





-t-i 





;,M 


TJ 






;h 


^3 


TJ 


^ 



O ft 

a> ft 

•3 CO 



ft'?: 

OT3 





73 














1 




03 




m ^* . 


.2 


hair 

itarc 
sues 

1. 


03 




"-i t» rrt 


'a 


,1 chaff 

wheat 
heat ti 
starch, 
starch, 
materi; 


0) 


'rt 


2 -c ^^^ ^ 


_o 


!- 


=U •- ^ 03_rH 


'a 


<ii rA v^ ^ -^ Qi'd 1 





oiS rt^ S 


s 




starch, 
starch, 
starch; 
luten eel 
starch, 
starch. 
w and CO 
•ked star 
all amou 
torted w 
ce of sta 


S 




00c 


^0 ^ § g.S g 




^'^'^ 




• • (M 


c^ 


CO rt^ ^ 




. . CO CO 


Oi (M O) a: 00 


qo-i^^S 










• • 


10 d (M* t-h" cci 








1-1 rH TfH 




CO Ttl T- 


CO Oi ^ 1-1 CO t^ T-i 




00 i-H CO TtH CO (M CO CO t^ 1 


asot^DBq; 








(M t^ C 


d d d d Cl oj CO 




CO c^ 


^ CO 


(S9:;'BjpAnoqjB3) 


10 CO CO Oi t^ (N t^ 1-1 Tti T-i 
t^ CO CO TjH CO Oi Oi 00 Oi 


a3jj:-ua3ojq.Tjs^ 


t-00^ 


TjH T-( CO 00 (M 


CO cOI> 


t^ t^ t^ 00 t^ 00 00 




(M Tt 


T-H CO >0 TfH CO C^ CO 


.-^ 


t^T- 


i-H CO t^ T-H t^ (M 


CO CO CO TJH 00 10 1-H -^ (N 1 










00:i> OJOTtHOOO-rH 1 


jsq.c^'Btu 


CO1- 


■ C^ t^ (M (M i-H O) 


paauij^ 


th co'cc 


CO CO (M (M (N i-H C^ 




CO 00c 


00 ^ CO 10 00 CO Tin 


(S.-9XM) 


Oi c: 


00 Oi LO C^ CO T-H "^ 


UI^:^OJ^J 


ci Oic: 


CO (>1 rH C^ 00 t-h' 










c^ 00 (M 


tH CO CO (M (M 10 




CO Oi rl- 


CO >0 i-H CO T-H rtH 


JS^^AY 








to TfH LC 


TtH CO CO CO 10 t- (M 




T-H C^ 




















6 d 














i 




^^ 














c3 




-ff^ 


=^^ 




73 




ft 




oi::; 


■^a 


fa 










4^^7: 


o-^ 


3 




6 




r;:^:^ cl 




Hi 


-^1 




"w "m ^ 


g|§*^o^ 




!>5>5 , 


03 .„ fa ^"^ •'^ !n ^^ 




^H 








C 

t: 
a, 
1^ 


1 


0. 




'a 




ti 






^^ 

s.a 
.^^ 

<v o 

rti f- 
-^^ ft 

O ij-i 

.a a> 
«2 ^ 

Cl CD 

^ a5 
rti ft 

a^ 

43 02 
^S 

^ cS 
5 =ci 



<u ftp. 

^ «2 fl 

b£-^ c3 

^.5 a 



'M 



O ft^ 
'^-^^ 

fi; 0.73 

.2-5 a 

• r2 (J3 *-■ 
^ w^ 

ft^ rt 

1— ( o '^ 

«.7:3 O 
•co S " 
oi R 02 

crj a> o 

•S^ ^. 

2"!:^ 



o 








03 








:n 












o 


o 


r. 


cS 


















T5 


o; 


+3 


'^ 


fcJD 


^ 



O 02 



^ <="• C3 






CS 5 1^ in -fi M ^ 

e3 -f^ o Si m 
! 43 03^ o ^ 



Sp^q, 



o o._ 



O 



qojB^S 



9SO:^0'B1 



O O O O O O O 



(S3:(.BJpAiIoqj-B3) 



^-^K 






O CO ■'ti O ^ lO o 
00 X Tti Tti 0*-H t^ 



O O O O O .-I O O rH 






ui3:).oj(j 



o r^ lo o th o2 C5 

O O Tfl O Ttl t^ o 



1-1 ,-( O T-H O CO • 



00 O CO O r-l O '^l o 

C00--(000>00 o 
1-1 (M CO CD O O l:^ T-^ 



I9;b^ 



1^ o d^ 

d bjO O) 0) 
:=! a; g g 



c3 

S g s 

•;? -d 
^ "S "§ 

l|§ 



d 
a; 
o 

c3 



O CO 00 O CO O O 00 CM 



1000>0>OCOIC05 T-l C5 



o 
o 

!^ 
m 

bjO 



! S 
o 
d" 

's 

d 

-^2 



CO . 

:d:^ 

^•§ 

co-^ 

§^ 



73 








a. 




















































c; 












c3 












02 






-M 






O 






o 


^ 






d 




o 




A 


e3 


"rt 


t 














f4 


O) 




ri 


a 


O 


« 




^ 










■^ 








00 








CM 








00 




o 


CO 




CO 


o 




o 


CO 






o 




Ttl 


00 




CO 


t^ 




00 


X 




CO 


o 




CO 


CM 




lO 


T— 1 




Tt^ 


Tt^ 




00 


CO 




o 


tH 




Tt^ 


1 CO 




1—1 


kC 




CO 


CO 




1—1 


CO 


Ir^ 


c 




^ 


cc 




o 


-r 








c 








c 








Pt. 








TZ 




T3 


0, 




O 






O 


c 




l^ 


0, 




r^ 


t 










^ 


x. 












< 




Q 


V 




O 


'•> 




a 


c: 




H 


ri< 




c3 


fi: 




^ 





-1 




1 










^ 






d 


a 




t^ 


O 


o 


Xi 


T3 


a 


O 
o 




fcX) 


>► 


d 


^:j 




O 


K) 




d 


rd 


o 


^H 


-+^ 


03 


&, 


-1^ 


a; 




Q. 


o 


a 


^ 


>, 
















a 


















d 






<D 














o 


CO 


02 


lO 








§ 


rd 






^ 


t^ 




CO 


^ 




O) 


TjH 


T3 


o 


O 






a 


o 






^ 






o 






a 




o 


d 


Tt< 


bfl 


1—1 


o 




-^3 






(U 




a 


00 


>5 


o 






CM 


■S 


o 


fl 




<v 


CO 


to 




^ 






CU 






<u 






Sh 






73 












a 






d 






o 


Ui 


Ui 


c 


bC 


TS 


.2 


o 


,d 


Ph 


H 


-iii 










'^ 


^ 


II 


o 


d 
bD 


O 


^ 


a 


"a 


4 

P- 





I 



144 DISEASES OF CHILDREN. * 

The composition of the food when it is in the infant's bottle will 
depend absolutely on how much of the proprietary food is used or 
on the richness and quantity of milk to which it is added. Thus it is 
manifestly impossible to give analyses which will give a correct idea of 
the nutritive value of these mixtures. 

There is one point, however, which should become fixed in the 
mind and that is that nearly all of the proprietary foods are com- 
posed of carbohydrates mostly, and these carbohydrates are largely if 
not entirely derived from cereals. Gain in weight is often made on 
these foods, but unless they are reinforced by milk the tissues are not 
of the firm muscular character produced by foods richer in proteins. 

Sometimes, as when traveling or when a good quality of milk 
cannot be obtained, the foods that are to be used without fresh milk 
may serve a useful purpose. But for general purposes of feeding these 
foods possess disadvantages over food mixtures for which the physician 
can write prescriptions to be followed by the mother or nurse, after 
he has become familiar with the principles and methods of artificial 
feeding. 



1 



CHAPTER XV. 
RISE AND DEVELOPMENT OF SCIENTIFIC INFANT-FEEDING. 

Historical. — The experience of many successful pediatricians in 
all parts of the world showed that infants did much better, as a rule, 
if part of their food was fresh milk of some kind, but it was also 
found that there was no animal that secreted milk having exactly the 
same properties as human milk. Therefore attempts were made to 
make cow's and goat's milk, which were the milks most available, 
correspond to human milk in composition and properties. Human 
milk was analyzed, as were also the other milks, and it was found 
their composition was apparently the same, except that the propor- 
tions of the ingredients varied. Cow's milk was richer in protein 
which formed curds in the stomach, so there arose the process of 
diluting milk for infant-feeding. It was found that diluting the 
milk with gruels made from cereals increased its digestibility by 
softening the curds. Later, it was discovered that if milk was pepton- 
ized the curds would not form, or if the milk was only partially 
peptonized the curds formed were very small, and peptonized milk 
for infants was looked upon as the solution of the problem. The 
action of bacteria on milk was recognized, and then sterilization, 
heating milk to 212° F., was introduced. After a time it was observed 
that sterilizing unfavorably affected the milk, and pasteurization or 
heating the milk from 150° to 165° F. was introduced. These proc- 
esses did a great deal of • good under certain conditions, but the 
problem was not yet comj^letely solved. 

It had been observed that human milk was slightly alkaline 
and cow's milk amphoteric, that is, both alkaline and acid, when tested 
with litmus-paper, and as the addition of lime-water or bicarbonate 
of sodium to the food often made it agree, the conclusion w^as drawn 
that the important difference between human milk and cow's milk 
was in their reactions to litmus-paper, and the routine addition of 
lime-water or baking soda to the food was looked upon as a funda- 
mental process. 

After a time it was taught that all milks were composed of the 
same substances, and that their differences were due merely to 
different percentages of the various ingredients and unlike reactions, 
lo 145 



146 • DISEASES OF CHILDREN. 

This teaching was widely accepted by many pediatricians, but it 
was observed that it was not always applied in practice by its expon- 
ents. When this fact became recognized, a new theory was brought 
forward, that the difference between human milk and cow's milk was 
due to the relative proportions of casein (the portion of the protein 
which is solidified by rennin) and albumin present in each, but this 
theory has been seen to be untenable, as it was found that caseins differ 
in properties and that the term casein is about as specific as the term 
wood. 

Since the subject of infant-feeding has been approached from 
the biological standpoint, the fallacy of the theories of making human 
milk from cow's milk, as has been taught, has become quite apparent; 
but as all of .these theories and teachings have been brought forward 
within comparatively few years and have been supported by author- 
ities, and will be met in practice for many years to come, an outline 
will be given showing wherein some of them are wrong and the prin- 
ciples upon which they are based. 

Fundamental Errors Made. — When the theory was put forth that 
the differences between human milk and cow's milk were due to un- 
iike percentage composition and reaction to litmus, two important 
errors were made. In determining the comparative properties of the 
solids made from the proteins of the two milks, acid was added to 
the milks, and rennin, or the gastric secretion of young animals with 
which the milk would come in contact in the stomach, was rejected 
as being an unsatisfactory reagent. The effect on milk of adding 
acid is totally different from that produced by the addition of rennin. 
The milk does not meet enough acid in the young stomach to precipi- 
tate it, but rennin which solidifies it is present; so this basis of compari- 
son was not only erroneous, but misleading. Acid will make a fine 
precipitate, while rennin makes a solid mass from cow's milk. 

It was laid down as a fundamental principle that the addition of 
5 per cent, of lime-water to whole milk gave it the same reaction as 
human milk and that this quantity was the proper amount to add 
to milk for infants. It was also taught that one to two grains of bi- 
carbonate of sodium to each ounce of infant's food produced the same 
result. But when it came to actual practice, 5 to 10 per cent, of lime- 
water was to be added to diluted milk. Thus it came about that any- 
where from 40 to 100 per cent, of lime-water was added to the actual 
whole milk used in preparing the food for an infant, as is seen in the 
following example of a food mixture often employed: 

Milk one ounce, lime-water one ounce, sugar one ounce, water eighteen ounces. 
Total, twenty fluidounces. Five per cent, of the food, or one ounce, is lime-water 



RISE AND DEVELOPMENT OF SCIENTIFIC INFANT-FEEDING. 147 

but this one ounce is 100 per cent, of the milk actually employed. If two ounces 
of milk were used instead of one ounce, the percentage of lime-water in the food 
would still be 5 per cent., but it would equal 50 per cent, of the milk. If 10 per 
cent, lime-water was added, as has often been recommended, in the first case the 
percentage of lime-water to milk would be 200 per cent, and 100 per cent, in the 
second instance. 

When lime-water is added to cow's milk it alters the casein so that 
it will not form a solid with the rennin of the stomach. 

Litmus is not a proper indicator to use in taking the reaction of 
milk as it is an acid itself, stronger than some of the acids of milk, 
the presence of which it fails to show. Casein is an acid, and. when 
rubbed in a mortar with calcium carbonate will drive off the carbonic 
acid (Van Slyke). Some of the acidity of fresh milk is due to casein, 
and also to the phosphate of calcium present. 

For testing the reaction of milk, phenolphthalein (1 per cent, alco- 
holic solution) should be used instead of litmus, and with this indicator 
breast-milk is also found to be acid in reaction. When lime-water is 
added to fresh cow's milk it is found that about 70 to 90 per cent, is 
required to make the milk alkaline to phenolphthalein. Breast-milk 
needs from 8 to 24 per cent, lime-water to make it alkahne. The effect 
of adding lime-water in such quantities as mentioned above is to 
modify the physical and digestive properties of the casein in the in- 
fant's stomach. 

If bicarbonate of sodium is added to the foregoing mixtures in the 
quantities often stated to be the equivalent of 5 per cent, of lime- 
water, that is, one to two grains to the ounce of food, twenty to forty 
grains would be added to twenty ounces of food. 

If there was one ounce of milk in the twenty ounces there would be added to 
it for the purpose of making it alkaline twenty to forty grains of bicarbonate of 
sodium, or at the rate of six hundred and forty to twelve hundred and eighty 
grains, or approximately one and one-half to three ounces to the quart of fresh 
milk. As one quart of soured milk will be neutralized by about one hundred and 
twenty grains of bicarbonate of soda, the error of adding at the rate of eight to 
sixteen times as much to fresh milk will be apparent. If bicarbonate of sodium 
was to be added in such quantity as to equal lime-water in power to neutralize 
acid, about three and one-half grains would be needed to replace one ounce 
of lime-water. Instead of this quantity twenty to forty grains have been 
recommended. 

Forty grains of bicarbonate of sodium will neutralize about twenty ounces 
of the gastric juice of the adult, containing 0.2 per cent, hydrochloric acid. 
One ounce of lime-water will neutralize a little less than one ounce of such 
gastric juice. As the gastric juice of infants is weak in acid, it is evident that 
the addition of these alkalies to the food has the effect of neutrahzing the 



148 DISEASES OF CHILDREN. 

gastric secretion, and preventing stomach digestiono The food remains fluid and 
is passed into the intestines and digested there. These additions retard stomach 
development, and in lower animals have been found to lessen the amount of 
nutriment assimilated from a given quantity of food. 

It will be seen that under the supposition that cow's milk was 
being made like human milk in its properties by altering its reaction, 
an entirely different effect was being produced, which goes to show the 
importance of not being too easily carried away by plausible theories, 
and of checking off standards based entirely on chemical data. In this 
instance an error in chemistry was made. 

Now that these errors have become recognized the alkalies are 
used with the understanding of their action and effect and their routine 
use is not considered as advisable as formerly. 

Similar errors were made in the theory that the differences be- 
tween human milk and cow's milk were due to unlike percentages of 
casein and albumin, which were supposed to be constant for each 
kind of milk. It has been stated with great confidence that there was 
one part of albumin to five parts of casein in cow's milk and two parts 
of albumin to one part of casein in human milk. Van Slyke who has 
made an exhaustive study of this subject in the milk of hundreds of 
cows supplying milk for cheese-making, which is based on the solidify- 
ing of casein by rennin, found there was no fixed relation between 
casein and albumin. It varied in herd milk from 2.6 to 5.6 parts of 
casein to one part of albumin. The proportion is different in the 
various breeds of cows and in the individuals of the breeds, and it also 
is different at different seasons of the year. In two Jersey cows the 
proportions were 3.7 and 6.3 parts of casein to one of albumin, and in 
two Holstein-Friesian cows they were 3.2 and 4.4 to 1. 

In addition to these wide fluctuations it should be remembered 
that caseins are not alike, so this basis has an insecure foundation to 
rest upon. In practice, when this theory is applied, a portion of the 
casein of the cow's milk is removed and alkali is added to the remain- 
ing amount which throws it into the intestine for digestion. 

These different methods of supposedly making human milk from 
cow's milk have all fallen under the heading of '^ modifying milk." As 
a matter of fact, none of the methods resulted in making human milk, 
and some of them were wide of the mark. Those who study the sub- 
ject carefully will see that what actually takes place in all of the 
methods of feeding which have been proposed is an adaptation of the 
food to the infant by one means or another. Milk is modified by all 
methods, but the principles involved differ widely. The following 
classification will be found helpfuL 



RISE AND DEVELOPMENT OF SCIENTIFIC INFANT-FEEDING. 149 

Classification of Methods of Modifying Milk for Infant-feeding. — 

All methods of modifying cow's milk for infant feeding naturally 
fall into seven groups, according to the principle involved: 

Group 1. Methods that affect the quantitative composition of 
cow's milk. 

(a) Simple dilution with water; (b) dilution with water with the addition 
of cream and sugar; (c) removal of a portion of the casein by adding rennin and 
then straining out the solidified casein or a portion of it. 

Group 2. Methods in which the character of the proteins of cow's 
milk are so altered that the rennin of the stomach will not solidify the 
milk. 

(a) Addition of lime-water until alkaline to phenolphthalein (5 to 10 per cent, 
of the food); (b) addition of carbonate of potassium until slightly alkaline {-^ 
grain to ounce of milk). If the stomach secretes enough acid to neutralize these 
additions the milk will solidify. 

Group 3. Methods that retard the solidification of milk by rennin 
and also neutralize any acid that may he secreted by the stomach. 

(a) Addition of 1 to 2 grains of bicarbonate of sodium to each ounce of food; 
(6) addition of syrup of lime; (c) addition of magnesium hydrate. These additions 
tend to prevent all gastric digestion and to throw the entire work of digestion on 
the intestines. 

Group 4. Methods in which the casein is precipitated in fine 
particles by acids. 

(a) Buttermilk feeding; (6) kumyss feeding; (c) matzoon feeding; (d) addition 
of dilute hydrochloric acid. In buttermilk feeding, lactic bacteria naturally in 
the milk, or those that may be added are allowed to grow and produce lactic acid 
which precipitates the casein. If the buttermilk is boiled before feeding, as it is 
sometimes, the bacteria will be killed, otherwise bacteria are also given in enormous 
numbers which may sometimes prove beneficial. In kumyss and matzoon 
feeding, bacteria produce acid which precipitates the casein* Yeasts may also 
be present. 

Any pepsin that may be secreted can readily act upon the proteins in the 
presence of the acids. Such foods may encourage gastric digestion. 

Group 5. Methods that profoundly alter the character of the milk. 

(a) Peptonization of milk; (h) addition of 1 to 2 grains of citrate of sodium or 
potassium to each ounce of milk employed. 

Peptonization completely alters the character of the proteins of the milk. 
Casein is in some way combined with calcium in milk. Citrate of sodium or 
potassium when added to milk produce citrate of calcium and caseinate of sodium 
or potassium, which will not form a solid with rennin. The calcium citrate is 
soluble in an excess of the precipitant and remains in solution. Acids added to 
milk in which the casein is in combination with ammonium, sodium, potassium, 
or lithium will produce a precipitate of casein like that of sour milk. Peptonized 
milk also remains fluid in the stomach. 



150 DISEASES OF CHILDREN. 

Group 6. Methods that indirectly alter the properties of the milk. 

(a) Sterilizing, boiling, or scalding the milk; (6) pasteurizing the milk; 
(c) using condensed or evaporated milk. 

Heating milk in some way changes it so the rennin ferment does not cause it 
to solidify as firmly or as promptly as does fresh milk, and it also destroys bacteria 
that might produce acid which would accelerate the action of the rennin in solidi- 
fying the milk. 

Group 7. Methods that mechanically alter the character of the 
solidified milk without affecting the action of the digestive secretions. 

(a) Diluting the milk with cereal gruels in which the starch is in a gelatinized 
condition; (b) diluting the milk with cereal gruels in which the starch has been 
converted into soluble starch, dextrin, and maltose. 

Laboratory Demonstrations to Illustrate the Effect of Various 
Methods of Modifying Cow^s Milk. 

As the literature of infant-feeding abounds with contradictory 
statements, concerning the effect of these different additions to milk, 
it is important that first-hand knowledge should be obtained, which 
may easily be had by performing the following experiments. Time 
spent in doing them will be well expended and will aid greatly in 
understanding many processes employed, and conditions met in 
practical feeding. 

Experiment 1. — Shows amount of lime-water required to neutralize cow's milk 
and breast-milk. 

(a) Make a 1 per cent, alcoholic solution of phenolphthalein. An ounce or 
even ten cubic centimeters will be enough. (6) Obtain some lime-water, (c) Place 
one drop of the phenolphthalein solution in a porcelain dish and add a few drops 
of lime-water. It should turn bright red. (d) Pour ten cubic centimeters of 
fresh milk into a clean dish, (e) Add one or two drops of the phenolphthalein 
solution and stir with a glass rod a few times. (/) Measure into a graduate or a 
graduated pipette, ten cubic centimeters of lime-water, (g) Add lime-water to 
the ten cubic centimeters of milk to which the phenolphthalein was added, one 
cubic centimeter at a time, and stir constantly until the milk becomes slightly 
pink in color. This indicates that the mixture has become alkaline. The number 
of cubic centimeters of lime-water added multiplied by ten will give the percentage 
of lime-water required to overcome the acid reaction of the milk. Anywhere from 
five to nine cubic centimeters of lime-water will be needed, which equals 50 to 90 
per cent, of the milk. If convenient, allow some of the same milk to remain over- 
night in a warm room to develop acid by souring and then see how much lime- 
water is required to make the milk turn pink after phenolphthalein has been 
added. As high as 200 or 300 per cent, may be needed, depending upon how 
far the souring process has proceeded. 

If possible procure a specimen of breast-milk and test as above. Anywhere 
from 10 to 25 per cent, lime-water will be required to make it turn pink. 

It will also be instructive to use red and blue litmus-paper in making these 
tests, especially so if different lots of litmus-paper are used. It will be found that 



RISE AND DEVELOPMENT OF SCIENTIFIC INFANT-FEEDING. 151 

most discordant results will be obtained. The litmus is not as sensitive as the 
phenolphthalein and will not give same results, and with different makes or lots 
of litmus-paper the same mixture may be shown to be acid, neutral, or alkaline, 
and the quantity of lime-water required to neutralize the same milk may vary 
widely if different lots of litmus are used. For this reason litmus should not be 
used in determining acidity in milk and results should not be accepted as final 
unless phenolphthalein is used as the indicator. 

The acidity of milk that causes trouble in infant-feeding is not that natural 
to the milk, but is that resulting from bacterial action after milk has been drawn. 
This distinction should ever be kept in mind. Alum when dissolved in water 
will have an acid reaction; borax when in solution will have an alkaline reaction. 
This does not mean that alkali should be added to the alum or acid to the borax 
solution to neutralize them! These reactions are caused by the alum and borax 
being hydrolyzed by the water, and any salt of a strong acid with a weak base will 
have an acid reaction, and any salt of a strong base with a weak acid will have an 
alkaline reaction when dissolved in water. If solutions of alum and borax are 
mixed in different proportions, the mixture can be made to have acid, neutral 
or alkaline reaction, and some solutions that are neutral may be made acid or 
alkaline by addition of water. Compounds having similiar properties exist in 
natural milk, and if it was known just what these compounds were, it might be 
possible to adjust the milks to be alike. In some milks the bases are stronger 
than in others and hence some milks show less acid reaction than others, although 
in all milks it will be found the acid reaction predominates. To those familiar 
with chemistry this slight difference of reaction in milks would be looked upon as 
of no practical value or significance, the real important thing from the chemist's 
standpoint would be to know what causes the difference. As a very slight change 
in the salts or mineral matter of the milk might alter its reaction, too much im- 
portance should not be attached to reactions oi fresh milk. 

Experiment 2. — Shows some effects of use of bicarbonate of sodium: Take a 
few grains of bicarbonate of sodium and dissolve in a little water in a test-tube. 
Add a drop of the phenolphthalein solution and also test with a strip of red or 
neutral litmus-paper. If the bicarbonate of sodium is quite pure it will be neutral 
or slightly alkaline. Now boil the solution for a few minutes and then cool it. 
Test again with the phenolphthalein and litmus. The solution will be found to be 
intensely alkaline. 

This test is instructive in that it shows what will take place in milk or infant's 
food to which bicarbonate of sodium has been added if it is pasteurized, sterilized, 
or scalded. The sodium bicarbonate is decomposed, some of the carbonic acid 
being driven off and carbonate of sodium remains which is decidedly alkaline. 
It is the familiar "washing soda." Some of the feeding mixtures that have been 
recommended, which contain large quantities of bicarbonate of sodium, when 
boiled, become mixtures of washing soda and milk. If one of these mixtures is 
made and well boiled and then swallowed by the physician, he will think twice 
before ordering it for an infant. 

Experiment 3. — Shows effect of rennin on milk. Obtain from a druggist 
some "liquid rennet," which is an extract of a young calf's stomach. Now se- 
cure some fresh cow's milk and test it for acidity with lime-water, as in experi- 
ment 1, to be sure there is no acidity caused by souring. If the milk takes more 
than 90 per cent, of lime-water to cause it to turn pink after the phenolphtha- 
lein has been added, incipient souring should be suspected. 



152 DISEASES OF CHILDREN. 

Add to about an ounce or two of the fresh milk two or three drops of the 
liquid rennet and pour from one vessel into another to cause a thorough mixture. 
Put in a beaker or cup and place in a dish of warm water to warm the milk to 
about body temperature. If the milk contains no preservatives or foreign salts 
or has not been kept long in rusty cans, it will soon form a limpid jelly and in a 
few minutes become quite solid. This is the first step in the digestion of milk and 
is what takes place in the stomach. The solid will soon begin to shrink and a 
greenish-yellow fluid will exude. This is known as "whey" and contains the 
albumin, sugar, and some of the salts of the milk. 

Experiment 4. — Shows difference between acid and rennin curds. Make some 
very dilute hydrochloric acid and add it slowly a few drops at a time to two ounces 
of the milk and stir until the milk precipitates. This precipitate is not like the 
solid formed by the rennet, which is composed of the casein of the milk in com- 
bination T^ith calcium in some form. The precipitate formed by the acid is a 
combination of casein and acid and has entirely different digestive as well as 
physical properties. 

Now add to about two ounces of the milk about one-third as much dilute 
hydrochloric acid as was required to precipitate it, but be sure the milk is not 
curdled after the acid is added. Then add two or three drops of the liquid rennet 
and mix as before and place in a beaker or cup in warm water. 

it will be observed that the milk solidifies much more rapidly than the fresh 
milk without the acid did, and becomes firmer. The acid accelerates the action of 
the rennin. 

This fact has a wide importance in infant-feeding, for lactic bacteria if allowed 
to grow in the milk produce acid all through the milk very much as yeast pro- 
duces gas in bread dough. In hot weather conditions are such that these bacteria 
produce acid in the milk very rapidly. If the milk is given to the infant it so- 
lidifies quickly and acid is constantly produced in the solid mass in the stomach, 
which causes it to become tough, stringy, and indigestible. The result is the 
infant vomits stringy curds or they are found in the stools, the infant suffering at 
the same time with colic. If milk is heated or pasteurized, the acid-producing 
bacteria are destroyed. Consequently in summer time it is often advantageous 
to pasteurize milk if the milk is not fresh or cannot be kept cool enough to prevent 
development of acid (under 50° F.). However, if clean milk of low bacterial 
count is obtainable, and it can be kept on ice until ready for use, there will be no 
necessity for pasteurizing to retard development of acid. This has been demon- 
strated on a large scale in tenement-house feeding where the preparation of the 
food was in the hands of trained physicians who could see that the food was 
properly cared for up to the time it was given to the infant. 

Experiment 5. — Shows how various additions to milk retard action of rennin, 
In small beakers or cups make the following mixtures: 

2 oz. fresh milk plus 1 oz. boiled water. 

2 oz. boiled milk plus 1 oz. boiled water. 

2 oz. fresh milk plus 1 oz. lime-water. 

2 oz. fresh milk plus 1 oz. water plus 2 grains of carbonate potassium. 

2 oz. fresh milk plus 1 oz. water plus 12 grains bicarbonate sodium. 

2 oz. fresh milk plus 1 oz. water plus 6 grains citrate sodium. 

It is well to number the beakers so that they shall not become confused. 
Allow to stand about five minutes to insure solution and then pour each mixture 
from one vessel into another a few times to secure uniform mixing. 



RISE AND DEVELOPMENT OF SCIENTIFIC INFANT-FEEDING. 153 

Now add to each beaker two or three drops of the Hquid rennet, mix thoroughly 
and set all into warm water and see how long it takes the milk to solidify. Some 
of them will never solidify, i.e., those with lime-water, carbonate of potassium and 
citrate of sodium. The specimen containing bicarbonate of sodium may solidify, 
but if acid is added an effervescence of gas will take place, showing the bicarbonate 
had not been decomposed by the acidity of the milk, and that it is present to neu- 
tralize any acid in the stomach. If this specimen had been heated it would not 
have solidified, as the bicarbonate would have been changed into carbonate which 
is highly alkaline. 

These foregoing experiments will show how the different chemical modi- 
fications of milk alter its character and behavior with the digestive secretions. 
It is well to state here that gastric digestion, when it is established, consists in the 
action of pepsin and acid on proteins, and that pepsin does not act in the absence 
of acid. It is obvious, then, that those modifications of milk which contain large 
amounts of alkalies will greatly retard or prevent gastric digestion. A glance over 
the paragraph on classification of methods of modifying milk will be helpful after 
performing these experiments. 

Infants Tend to Adapt Themselves to Their Food. — One of the 

inherent faculties possessed by all forms of living things is the ability 
to change their form and functions, to bring themselves into harmony 
with new or altered conditions of life, if the altered conditions are 
brought about gradually. The development of callous on the hands of 
one unused to manual labor as soon as rough materials are handled is a 
familiar illustration of this fact. The acquirement of tolerance for 
drugs, and immunity to certain diseases after one infection are other 
illustrations. 

Similarly, the feeding or nutritional habits of animals can be 
modified to a greater or less extent. It is possible by careful manage- 
ment to develop in a carnivorous animal herbivorous habits of feeding, 
as is often seen in house cats which are fed exclusively on vegetable 
food. The one thing to be avoided in such feeding is too radical and 
too sudden changes in the form of the food, as the animal then does 
not have sufficient time to adapt itself to the new conditions. 

In infants this ability of adaptation to the food is present to a 
marked degree, and much of the credit that goes to the successful 
feeder is due to the unconscious cooperation of the infant, brought 
about by making the changes in food gradually, giving it time to adapt 
itself to new food conditions. Those in which the power of adapta- 
tion is dormant form the greater number of the difficult feeding cases. 

It is also due to this power of adaptation that some infants 
can survive and grow on food that would kill other children. There 
is a limit to this faculty, however, and it is more strongly developed 
in some infants than in others. When properly utilized it is of great 
assistance to the physician, but it should not be abused by allowing 
any kind of food to be given and trusting to the infant to get used to it. 



154 DISEASES OF CHILDREN. 

Infants Differ in Digestive and Assimilative Efficiency. — It has 

been often observed that some infants will thrive and gain in weight 
on an amount of nutriment that others of the same age fail to gain on, 
and that some infants gain in weight more rapidly on the same quantity 
of food than other infants do. This fact has been perplexing to many, 
and has led some to believe there was no science in infant-feeding, each 
infant being a law unto itself. But widely extended experiments on 
animals have shown that they differ greatly in their efficiency in appro- 
priating and utilizing food, the organs of assimilation being nearl}^ 
twice as efficient in some animals as in others of the same species. 

Assimilation Most Efficient in Early Infancy. — The capacity for 
assimilation of food is not the same at all periods of growth. It is 
greatest during the early part of infancy and becomes gradually less 
as maturity is approached, until no matter how much food is eaten 
only the normal metabolic loss is made good, and fat is stored up, 
any excess of proteins being excreted. Young infants have been 
found to store up 70 per cent, of the proteins of their food, and 
young calves have also been found to convert this same percentage 
of proteins into tissue, but in the adult as much nitrogen as is taken in 
as protein is excreted, so none is fixed as new tissue. Therefore a 
sufficient quantity of tissue-building food (protein) early in life is of 
the greatest importance from a point of economical use of food and 
for promoting vigorous growth. In producing meat for market this 
fact is taken advantage of by scientific meat producers as it adds to 
their profits. It is also important in another way, for at this period 
the digestive organs, liver, kidneys, and heart are developing rapidly, 
and the size and strength of these organs will depend upon the supply 
of building material available, which is protein. 

There have been those who did not take into consideration the 
great power of assimilation during early infancy who have advocated 
the use of a very small quantity of proteins in the infant's food during 
the first few months of life, not over one-third as much as supplied by 
the mother, to avoid digestive troubles. Of course, if an infant has 
indigestion its food should be reduced to its digestive capacity, but 
no greater mistake is made in infant-feeding than to keep infants on 
food containing a small quantity of protein for any length of time, for 
as the infant becomes older, increasing the quantity in the food is off- 
set by the lessened capacity of assimilation. Proper feeding in the 
first few weeks or months after birth insures good development and 
freedom from trouble later on. If an infant is badly fed during this 
formative period, its management later on may be a tedious and 
difficult matter. 



CHAPTER XVI. 
PRACTICAL FEEDING. 

Basis of Practical Feeding. — No matter how much the actual 
processes employed in preparing food for infants may differ, they 
all have for their object the combination of protein, mineral matter, 
fats, carbohydrates, and water in some form that will be acceptable to 
the infant. It has been shown on pages 129, 130 that it is important 
for these ingredients to be present in the food in certain relative 
proportions if the infant is to develop properly, and with the least 
amount of waste of digestive and assimilative effort. It is likewise of 
importance to understand methods of calculating the quantities of the 
food elements in any food mixture, and how to determine the quanti- 
ties of milk, cereals, sugar, and other materials necessary to use to 
produce different food mixtures containing any desired quantities of 
protein, mineral matter, fats, carbohydrates, and water. The best 
practice is to think of the percentage composition of the food, and 
many times the cause of digestive disturbance in infants can be deter- 
mined by working out the approximate percentage composition of 
their food from the formula used in making it, when it may be found 
that one or more ingredients — that is proteins, fats, or carbohydrates — 
are present either in excess or in too small quantity. 

Percentage Milk Mixtures in Infant-feeding. — As was stated on 
page 134, the best milk to use in feeding infants is that produced 
under sanitary conditions, bottled at the dairy and kept iced until 
delivered to the family. When such milk is delivered the cream has 
risen and appears as a distinct layer at the top of the bottle. If the 
bottle of milk is shaken to mix its contents, the milk will then have a 
uniform composition which will almost always fall between the 
following extremes: 

Protein Mineral matter Fats Carbohydrates 

3%-3.5% 0.6%-0.8% 3%-5% 4%-6% 

To make simple approximate calculation of the quantities of these 
elements that cow's milk imparts to a mixture, it is best to take the 
mean composition of commercial cow's milk as a working basis, especi- 
ally as a large part of the bottled milk has about this composition. 
If milk above this mean is used the error cannot be great, and if 

155 



156 DISEASES OF CHILDREN. 

below the error will also be small. For this reason it is advisable to 
take as a working basis the following figures: 

Protein Mineral matter Fats Carbohydrates 

3.2% 0.7% 4% 5% 

At one time the figures proteins 4%, fat 4%, and carbohydrates 4% were used 
but as the error in proteins was about 25% they are not being used so much. 
Some take the protein as 3.5%-, but this is rather high for the general run of milk. 

If a feeding mixture contains one-fourth milk, the quantities of 
the food elements supplied by the milk will be one-fourth of the 
foregoing figures or: 

Protein Mineral matter Fats Carbohydrates. 

4[ 3.2% 0.7% 4% 5% 

0.80% 0.18% 1% 1.25% 

If the proportion of milk in the food was one-third, one-half, one- 
tenth, or any other fraction, the composition of the food would be 
determined in the same manner. 

Top Milk. — When whole milk is diluted for infant-feeding the 
proportion of fat in the diluted milk is too small for most healthy 
infants, as is also the quantity of sugar or carbohydrates, so it is 
necessary to add these elements. The quantity of protein in cow's 
milk is too great for most infants to digest, and more than they require 
for growth, and therefore it is to reduce the quantity of proteins that 
the milk is diluted. 

Formerly the addition of cream to diluted milk was a favorite 
method of adding fat, as it is essentially milk extra rich in fat, the 
protein and carbohydrates being present in but slightly less quantities 
than are found in whole milk. However, several objectionable 
properties of cream make its use inadvisable. First, its composition 
is not uniform, and then it may be old and heavily laden with bacteria 
which will infect any sanitary milk it may be mixed with; and, again, 
it may have been passed through a centrifuge, and had its natural 
emulsion destroyed (see page 137), so that it becomes more oily. In 
addition to these material objections, it is a difficult matter for many 
to calculate the composition of food made with cream and milk, and 
great errors in the composition of the food result from mistakes in 
the arithmetical process, the infants often suffering from the im- 
proper food. 

These drawbacks to the use of cream have caused this method 
of adding fat to the infant's food mixture to be largely supplanted 
by the top-milk method, which is simple and exceedingly accurate. 



PRACTICAL FEEDING. 



157 



As was stated above, when milk is bottled and kept cool the 
cream rises to the top of the bottle and forms a distinct layer. This 
cream contains nearly all of the fat of the milk, the milk under the 
cream layer often containing only 0.4 per cent, of fat, while the 
cream at certain levels may contain as high as 25 per cent, of fat. 
The layer of cream is not uniform in composition, as will be seen by the 



OlSnUBUTiDNOFHTiNGT 
BOTTLE 0F4>:MILK.EM:H OZ, 
REHDYEO WITH DIPPER 




LAYER OF CREAM' 

NOT UNIFORM IN 
COMPOSITION 



FAT IN DIFFERENT PORTIONS 

REMOVED FROM THE TOP 

AND MIXED. 



2^01. TOP 2 02S.MIXED 24 5« FAT 




Fig. 42. — Percentages of fat in different portions of a quart bottle of milk. 



illustration of the amount of fat in each ounce removed from the top 
of a quart of milk containing 4 per cent, of fat even on which the 
cream had not completely risen, as is shown by the high percentage 
of fat in the milk under the cream layer. 

At one time it was believed that cream which rose of its own 
accord, and known as gravity cream, was uniform and contained but 
16 per cent, of fat; and as very often the cream to be added to the 
infant's food was taken directly from the mouth of a quart bottle, 



158 DISEASES OF CHILDREN. 

instead of the infant getting 16 per cent, fat cream, one containing 25 
per cent, or more of fat was obtained. | A common thing at one time 
was to see infants suffering from fat indigestion caused by an excess 
of fat thus unwittingly introduced into the food. ; 

It is evident that if all of the fat of a quart of whole milk contain- 
ing 4 per cent, of fat rose to the surface, the top or upper pint, or one- 
half of the quart of milk, would contain twice the percentage of fat in 
the original milk, or 8 per cent., while the remaining pint would contain 
no fat at all. If all of the fat was in the top one-third of the quart of 
milk it would contain three times 4 per cent, or 12 per cent, of fat. 

As a matter of fact, nearly all of the fat in a quart of milk is found 
in the top six to eight ounces after the cream has risen, so by taking 
all of this layer of cream with some of the fat-free milk underneath, 
milk containing 1^, 2, 3, or any other number of times as great a 
percentage of fat as the whole milk contained may be had from the 
ordinary quart bottle of milk. As a smalKpercentage of fat remains 
in the milk below the cream, a little less than the above theoretical 
quantities are removed from the top of the bottle. 

These top milks, as they are called, contain about the same 
quantities of protein, mineral matter, and carbohydrates as whole 
milk, so when using whole milk or top milks for dilution the per- 
centages of all the elements except the fat will be the same no matter 
which is diluted. Therefore, by using definite quantities of the upper 
part of a quart of milk after the cream has risen the amount of fat 
in the diluted milk can readily be varied, while the percentages of the 
other elements remain unchanged. For example, there could be 
obtained top miilks containing 

Fat Carbohydrates Protein 

6% 5% 3.2% 

7% 5% 3.2% 

8% 5% 3.2% 

10% 5% 3.2% 

12% 5% 3.2% 

16% 5% 3.2% 

And if each was diluted four times the diluted milk would contain 
percentages equal to one-fourth of these figures, or 

Fat Carbohydrates Protein 

1.5% 1.25% .80% 

1.8% 1.25% .80% 

2.0% 1.25% .80% 

2.5% 1.25% .80% 

3.0% • 1.25% .80% 

4.0% 1.25% .80% 



PRACTICAL FEEDIXG. 



159 



The percentages of the elements in any dilution can readily be de- 
termined in the same manner. 

To obtain these different top milks the dipper^ shown in Fig. 44 
is used. It measures one ounce. 






Fig. 43. — Quart bottle of milk, 
showing layer of cream. 



Fi^. 44.— 
Chapin cream 
dipper. 



The following key by Deming shows how to find the percentages 
of the food elements if the proportion of milk or top milk in the mix- 
ture is known, and w^hat proportion of milk or top milk to use to ob- 
tain any desired percentage combinations of the milk elements. 

Percentage Cereal Gruels. — Until comparatively recently the use 
of cereal gruels has been purely empirical, and little attention has been 
paid to their composition or nutritive value. But recognition of 
the benefits to be derived from their intelligent employment is leading 
to their being used in a scientific manner, and the tendency is to pre- 
scribe them in definite quantities and of approximately definite per-. 
centage composition. The composition of cereal gruels depends 
upon the cereal employed in making them and also to a much greater 

lit is known as the Chapin Dipper and is sold through the wholesale druggists. 
It can be obtained by mail of Cereo Company, Tappan, N. Y., for fifteen cents, 
made of heavy tinned steel, or of aluminum for twenty-five cents; also from Jas. 
T. Dougherty, 411 West Fifty-ninth St., Xew York. 



o 



o 

a 



fcJO 
o 









5 ^S 

'^.'^ PL, O 



pq «^ 



>,« o - 
pq 






b£ 



^'bS 



PQ 



'^ r^ ^ fe- 

o 



o ^ d hjo fvj 
o .T3 ^ ;;: cd 

"^ o ^ X 



lO O LO o >o o ^ 
T-( CO '^ CO t^ Oi o 



CO lO t^ O (M lO o 
tH (M CO lO CO 1> GO 



00 

00 1> CO lO TlH c^ o 

1-1 (M CO TjH lO CO 



t^ lO (M O t^ »0 (N 

1-1 C^ CO CO TfH >o 



CO (M 00 lO O t^ '^ 
1-1 rH (M CO CO ^ 



o 

lO O lO O lO O lO 
T-( T-l (M Cq CO CO 



o o 

rti 00 (N CO O '^^ 00 
1-1 T-l C^ CM (M 



"S cr i^ S i d 

d d ^ d > ^ a^ 
o o -fj o cd -M cc 






C3 
• CQ CO ^ '^ ^ 



d 
o 


11 


11 


11 


11 


ir 


ri^ 






<D 


(U 


a 


Cl 




fin 






!^ 




't 


M 


y 


^ 


d 


■^ 


X 










^ 


aas 


g 


a 


'g 






(U 


0) 


Q> 


rd-d 


^^^ 




-f^ 


-M 








-o 


^ 


'o 


o 


'o 


d 


-p 


-!:; 


HSHS 


H-^ 


7:3 













d 

.a 

b «2 

O) 

I— I -+^ 

Oj 

II . f-i 

N^ 

Jh O >;> 

(73 , rd 

be'"' O 

d II rO 

'^ b '^ 

a-> c3 , 

-+-» bjOT3 

=2 d d 

3 M (7j 

f^^ d 

faca-g 

m cc jh 

tM q-H «+_, 

d d o 

Ph D^ bjO 

c3 c3 5^ 
"^^ " 

■'o3 o, 

OJ O) ^H 

(NCOfii 



O 
CO 



o +^ 



6^ 

!^ Si 

OS'S 



. ;3 

I— t Ui 

-< o 

H ;-^ 

'w 
O 

a, 
B 

o 
O 

0) 

W) 



CO 

^ a 

S-i ^ 



O -^^ 



T-iroooxiOT-ico 



(M LO t^ O CO LO GO O 
O T— I rH 1— I 1— I (N 



T-i(NCOTfiLOaDt^00 

i-HCOTtlCOGOOr-l(N 

(M Tti CO C/D O iM lO t^ 



1— iC^COThliOCOt^OO 
COCjDCi(N'OCO'-HTtH 
COOOCOOOCOCO 



T-H i-H T-H (M CSI 



COCOCiC^LOGOi-HTtl 
(MrficOOOOO'^O 



LO O lO O to O lO o 
CiOJOOOOt^t^COCO 
rHCOLOt^Oii-HCOlO 



,^^.^^-(^-^J-^^-^3-^^-^J 



:3 ^ 



2^ 



crcr 



o o 



d d d ci d d 

^ ^ 3 3 3 ;3 
cT cT cr' cT a" cT 

o o o o o o 

-fj .+J -t^ +J -M +3 

ui m in m m m 

a; Qj iX) (X) Qj (1) 

o o o o o o 

fl d C C cJ d 

^ ^ ^ ^ ^ ^ 

o o o o o o 



c^ ro '^ .O O !>• 00 



r. O " 

^:: W 

«= h^ 



!» m I— I 



c1 c3 



o 


cS 




O 


X! 


a 


o 


d 


s 


T3 




r1 


T1 


2 


ci 


J 


a; 


>? 


rli 


d 


-t^ 


a 


o 




d 




fl 


a; 


d 


13 


o 




r/j 


fcJU 










t>C ?£ 




•cS> 




■CO 



a,Q 







6i^ 


^ ^ ^ ^ ^ ^ 


^ 






^ C3 


C^ >0 00 o o o o 








O (N 00 lO O O O 






o >. 


d 1-H 1-1 (m' LO i>i d 






1— 1 




P4 














a 








^ 


,g 


^ ^ ^ ^ ^ ^ ^ 






o 


o o o o o o o 






o 


rH (M CO Tfl 00 (N O 






Ph 


d d d d d i-I 1-H 






6^ 


^ ^ ^ ^ ^ ^ ^ 






^ d 


o o o o o o o 






!-( ^ 


O C^ 00 TtH 00 (M CO 






c3 "^3 




xn 




O !>^ 


O rH i-H (N TtH t^ Oi 


3 


f-' 






o 


o 






E 






-o 




_d 


^ ^ ^ ^ ^ ^ ^ 






"S 


(N rf* O CO CO Tt^ (M 




o 


7-H (M CO Tti O rti O 




^1 


d d d d d ^' ^' 


fl 








rt 
















a 




4l 


^ ^ ^ ^ ^ ^ ^ 




Xi <^ 


CO CO c: (M '^ O 00 


o 

Vh 






O O O i-H (N CO '^ 


i 


O -H ^ (N '^ CO 00 


<U 




^ 




TS 


t3 

a 






1 






J2 


h^l 


_d 


^ ^ ^ ^ ^ ^ ^ 


3 




"? 


O O 00 CO O Tti (M 




o 


1-H CO O t^ 'O CO r-H 






Ph 


d d d d ^ (N CO 


MH 








o 








o 




O -^J 


^ ^ ^ ^ ^ ^ ^ 


•^ 




^ 03 


o o o o o o o 


•r< 




T; !- 


O CM 00 ^ 00 CM CO 


2 




03 T3 




Ph 


pq 


O >;^ 


O r-H T-H CM ^ t^ O 


a 


'^ 




o 
O 

4> 


.a 


^ ^ ^ ^ ^ ^ ^ 


a 

o 




"_s 


CM 'f CO 00 CO ^ CM 




o 


1-1 CM CO rfi O ^ O 




Ph 


d o d o o 1-H 1-1 








;h 






o • '-^ 


,. s 


+^ • o 


o 


o • 


Pi 
< 






si 
o 


IS] 

O 


• si 

O 






isj • 








. ^l-t 


-^ 


^ 


o ■ o 


O 


o ; 








^— ' 


o 


:3 
o 
q=l 


^ ; CM 


CO 


^ • 








Id 

o 


tS3 . ^-^ 

O . 


Sh 


^ '. 








q:^ 


^ 


CTi 


c : ^ 




3 . 








3 


c^'oS^'o ^ '.q:^ 


o 
q=l 


o . 








§ ^ o =* o =^^ . 3 =s 3 :=i ^ d 








^bjn«30coOtd .SHbjOs-(b£i-ibX) 














'^, <u <V IZ <D <V (V 








3 O X2 fH ^ Sh ^ -^ > O g O g O 




















_I c3^ ^^ ^-- W)_ c3^ 03_< 03 








'^ 13 O -, QJ „ O^ O 3 1^ 3 J* 13 














^J] K^ ^^ h-l K-^ H^ h^ 








1 rH 


CM 


CO 


T-l CM 


CO 


^ 1 



162 DISEASES OF CHILDREN. 

extent upon the condition of the cereal, that is, whether it is in the 
form of flour, granulated, or in the whole state. If flour is used in 
making the gruel and none is removed by straining, dividing the com- 
position of the flour by the number of parts of gruel made from one 
part of flour will give its composition; as, for instance, a gruel made 
with one ounce of flour to the pint would be one-sixteenth as strong 
as the flour. But when whole or granulated cereals are used, a large 
part of the proteins and considerable of the carbohydrates are removed 
by straining, as the cereal does not disintegrate while cooking and 
the composition of the gruel is not in proportion to the composition 
of the cereal employed. 

In using ordinary cereals in preparing gruels the following quan- 
tities will be approximated, when a tablespoon is used in measuring 
the cereals. 

1 level tablespoonful of pearl barley weighs ^ oz. avoirdupois. 
1 level tablespoonful of barley flour weighs ^ oz, avoirdupois. 
1 level tablespoonful of wheat flour weighs i oz. avoirdupois. 
1 level tablespoonful of rolled oats weighs I oz. avoirdupois. 

When the ordinary cereals are made into gruels they will have 
approximately the following composition (see Table I) : 

If all of the rolled oats had remained in the gruel made with 
one ounce to the quart, the gruel would have contained about 0.50 
per cent, proteins, as these rolled oats contained about 16 per cent, 
proteins, but the gruel actually contained but 0.26 per cent, proteins, 
showing half of the proteins were removed when the gruel was strained. 

There can now be obtained through the drug stores a series of 
standardized flours for making gruels known as Cereo Gruel Flours, 
put up in tins the covers of which measure one ounce of flour. On 
the labels is given the quantity of flour to use to make a gruel of any 
desired composition. Gruels made from these flours contain more 
proteins than gruels made from ordinary cereals, as will be seen by 
comparing the composition of gruels in Table II with those in Table I. 

Percentage Composition of Milk and Gruel Mixtures. — When milk 
or top milk is mixed with gruel the percentage of fat in the mixture is 
not affected by the gruel, as gruels contain negligible quantities of 
fat, but the percentages of protein and particularly those of the carbohy- 
drates, are much greater than when milk is mixed with water. The 
following table shows the amount of proteins and carbohydrates in 
various dilutions of milk when gruels made from the standardized 
gruel flours mentioned above are used. 



S 2 



O 



1 1 



«*H in 



o 



b£ 

o 

73 



o 



([^jBnb oi xnc-g. ptuS jo 
sinjuoodS9jq-Eq.pAai3i) -szo £ 



s|Tijuoods3jqB4. pA3j 8) -szo z 



(■^zvnh oq. Jnop pruS jo 
S[njuoodS9|q'B:; pA9j t') 'zo i 



(:pBnb oq. anog piuS jo 
pajuoodsa^qn;. pAS^ i) -zo ^ 



O O O lO lO O O 

CC CO CO >0 O lO ^ 



CO Tt< »0 lO CO oc o 

T^ ^^ ^ ^^ ^^ "^ ^O 



<^ t^ O Lo o re CO 

(N (N CO CO Tti TtH Tti 



i-H CO (N t^ CO O Tt< 

rH i-H (M (M CO CO TjH 



j (qj-enb oq. Jnog pruS jo 

I spjuoodS9^q-B;pA9^ CI) -szo £ 



1 : ^ 



CQ 



(^.jBnb o^ Jnog pruS jo 
S|njuoods9[qB; pAgj g) -szo z 



O CO -^ 1-H X lO CO 
1> CO CO CO O O UO 



00 00 c; o o o o 

■* Tfl ■>* M^ >-0 Tfl lO 



(:^-Bnb o; anop ptu3 jo 
spijuoodsgiq^q. pA9i P) -zo i 



(IJBnb oj anop j9ru3 jo 
pjuoodS9[q-Bq. pA9^ i) -zo ^ 



t^ O -vO t^ O CO t^ 

(N CO CO CO '^ Tt^ -^ 



IXM 00 CO O -^ 
1-1 (M (M CO -^ -^ 



(;jBnb oi JTiog pnoS jo 
spajuoodS9^q'B:;.pA9isi) -szo £ 



dj-enb oq. Jnog ptuS jo 
s^nJuoodS9Iq■B:^ pAaj g) -szo z 



Tf LO CO t^ C^. O (M 
(M (M M C^ C^ CO CO 



t^ 05 <N CO CO 00 O 
i-i(M (N (N (N CO 



(qjBnb 05. jno^ pruS jo \ 
spjuoodsgjqBq. pA9[ t') -zo i 


T-l rti t>. CO CO C5 

^ ^ ^ (m" cci (N (m" 



(laBnb o% Jnoy: pruS jo 
pjuoods9tq-B; pAgf i) -zo ^ 



CO tJ< 

>0 05 CO t^ (M -^ 00 



(ri-j-Bnb oq. Jnog pruS jo 
spjuoodsg^qBq. pA9j zi) -szo 9 



(jjBnb oq. anop pnaS jo 
synjuoodsa^q-eq. pA9[ g) "szo z 



(:^J■Bnb 05. jnog pruS jo 
SJTlJ^oods^^q■B:^ pA9^ P) -zo i 



(l-JBTib oq. inog ptuS jo 
[njaoodS9jq-e4 pA3| i) -zo :^ 



^ ^ (N Ol C^l 


CD c: T-H CO Lo t^ 

Ti ^ (N (N (N (m' CO 


(N 10 00 CO CO c; 



1-1 1-1 .-I c^ oq ^J c^ 



(M coo O O O CO 
00 T-( iCi 00 (M >0 00 



i-H i-H i-i(M (M <N 



o c; 10 CO -^ CO 1-1 

>-0 X (M CO O Ti^ 00 



i-H r-i (M (N (N 



pruS JO uoyqjodojjj 



5[]r[ll JO IlOiqJOdOJJ Ha:H-«■«*0HNlCia;«H<^4a6 



CO 
CO 



. 



1G4 DISEASES OF CHILDREN. 

Illustrations of Use of Previous Tables. — Wide experience has 
demonstrated that there are certain percentages of each of the food 
elements more than which it is not safe to have in the food of most in- 
fants, and other percentages less than which the food should not con- 
tain as it will not be sufficiently nutritious. 

It is seldom advisable to have the food of infants contain over 
5 per cent, of fat, 8 per cent, of carbohydrates, or 3.5 per cent, of pro- 
teins. The mineral matter in mixtures is generally sufficient, and as 
yet no attempt has been made to deal with the complex substances 
that make up this element of the food. 

For the great majority of infants the maximum percentages just 
mentioned should not be employed as they will cause disturbances, 
and it is only after a period in which the strength of the food is grad- 
ually increased that high percentages can be tolerated by any infants. 
However, many times infants are given as great or greater percent- 
ages inadvertantly by those who do not estimate the composition of 
the feeding mixture, and a great deal of unnecessary disturbance 
results. 

For instance, an infant is given a mixture composed of the top nine ounces 
from one quart of milk, nine ounces of water, and one ounce of sugar. It vomits 
a great deal and is not doing well. By reference to the key to composition of milk 
mixtures on page 160 it will be found that a mixture containing one-half top milk 
made by using the top nine ounces from a quart bottle and one-half water will 
contain 6 per cent, fat, 1 . 6 per cent, protein, and about 1.6 per cent, carbohydrates. 
The one ounce of sugar added would be a trifle over one-twentieth of the mixture, 
or 5 per cent., which would bring the percentage in the mixture up to over 7 per 
cent. The mixture would be looked upon as being composed of fat 6 per cent., 
carbohydrates 7 per cent., and protein 1 . 6 per cent. As vomiting is often caused 
by too much fat in the food, the inference would be that as the percentage of fat 
was above that found to agree with most infants it should be cut down. A 
glance at the key shows that if the top twenty ounces is removed from the bottle 
and mixed to make its composition uniform and is then diluted in the same pro- 
portion, that is, equal parts of the top milk and water, the percentage of fat in the 
mixture will be 3 per cent., which would be about what would be suitable for 
most infants. If this top milk was substituted for the top nine ounces and the 
infant had no more difficulty with its food, it would be conclusive that an excess 
of fat caused the trouble, especially if the stools were sour-smelling and frothy. 

Another infant might be seen who had sour, watery movements that irritated 
the skin. Its food might have been made as follows: Whole milk, eight ounces; 
wheat-flour gruel (two ounces flour to quart), eight ounces; granulated sugar, 
two level tablespoonfuls; total, sixteen ounces. Referring to the table on page 163 , 
showing the composition of milk and gruel mixtures, it is found that a mixture 
half milk and gruel (two ounces flour to quart) contains 2 per cent, protein and 
4.9 per cent, carbohydrates. From the key on page 160 it is found that two 
level tablespoonfuls of granulated sugar weigh one ounce, which would be one- 



PRACTICAL FEEDING. 165 

sixteenth of the mixture or slightly over 6 per cent. Thus, to a mixture containing 
4.9 per cent, carbohydrates there is added 6 per cent, more, making a total of 
practically 11 per cent, carbohydrates in the food. Few infants can digest and 
assimilate much over 7 per cent, to good advantage, and the indications are that 
in this case the excess fermented and produced acid discharges. One-half a level 
tablespoonful of the sugar, 1^ per cent., is about all that should have been added, 
as this would have made the total about 7 per cent. 

In the case of a very young infant suffering from colic, and with curds in the 
stools, a mixture containing three parts of milk to one part of water might have 
been given. Referring to key on page 160, it will be found that a mixture con- 
taining three-fourths milk will contain 2.4 per cent, protein, from which the curds 
are formed. Experience has shown that young infants should not at first have 
over 1 per cent, of proteins in their food, as their digestive organs are not suffi- 
ciently trained to digest more than this quantity, when not in the form of protein 
of breast-milk. 

If the proportion of milk was made one-fourth instead of three-fourths, in all 
probability the colic would disappear, as would also the curds in the stools. Of 
course sugar would have to be added to milk so highly diluted to save the infant 
from living on its own tissues. About one part of sugar to sixteen parts of food 
would be required. 

There was a time when it was firmly believed by many that all of 
the digestive disturbances of infancy could be successfully treated by 
thus altering the percentage composition of the food, but it is now 
known that other factors are involved, and that w^hile adjustment of 
percentage composition is an important matter, still there are other 
points equally important to be taken into consideration. 

It is only a waste of time and energy for the physician to commit 
to memory lists of percentages suitable for different ages and con- 
ditions. If he will study each case as it presents itself and work out 
the composition of each food that is disagreeing, he will soon come to 
understand what percentages to use to get best results, and also to know 
what other methods besides changing percentages to employ under 
different conditions. . 

Outline of Feeding Directions. — It is im.possible to give explicit 
directions for preparing food for each particular infant, as infants 
differ in their digestive capacity and in their efficiency in assimilating 
food, as mentioned on page 154, and in their condition when the physi- 
cian is called in. However, all cases naturally fall under about four 
headings: (a) Well infants which cannot obtain breast-milk, and 
the control of w^hich the physician has from the start, (h) Infants 
that are well except that they are suffering from bad methods of feed- 
ing, (c) Infants of feeble constitution whose digestion is easily 
deranged, (c?) Infants that are acutely ill. Before attempting to 



IGG DISEASES OF CHILDREN. 

feed an infant, its feeding history should be carefully taken to deter- 
mine in which class the infant belongs. 

The methods of feeding these different classes of infants vary 
considerably, and while the same general principles hold, they must be 
applied differently. In all methods attention must be paid to per- 
centage composition of the food. This is not a difficult matter, and 
can be readily learned, but the skill and ability of the infant feeder 
have a chance for display when it comes to adapting the form of the 
protein, fats, and carbohydrates to the infant; or to modifying the 
action of the infant's digestive secretions on its food by various 
additions to the food as explained on page 149. In the suggestive 
feeding mixtures given here the preparation of the food is sharply 
divided into two parts: First, adjustment of the quantitative or 
percentage composition. Second, modification of the form of the food, 
or the action of the digestive secretions on the food. 

Food for Healthy Infants. 

The object in preparing food for healthy infants is to so modify or 
adapt the food that they will be well nourished and have their digestive 
organs so developed that the infants will become able to take whole 
cow's milk without digestive disturbance. It is generally about the 
ninth to twelfth month before this is possible, and if alkalies or antacids 
have been added to the food in too great quantities it may be later, 
as these substances seem to interfere with the normal development 
of the stomach. 

In reality the whole process amounts to a training of the infant's 
digestive organs, and it is important to commence in the early months 
with small quantities of the protein of cow's milk, as this causes the 
greatest amount of trouble, moderate quantities of fat, and a liberal 
supply of carbohydrates, as these cause little digestive disturbance 
when not given in too great excess. The fats are kept in the neighbor- 
hood of 3 per cent, during the whole period of artificial feeding, and the 
carbohydrates at about 6 per cent, or 7 per cent., seldom over these 
figures. But the protein is managed in an entirely different manner. 
At first the protein is given in as small a quantity as 0.4 per cent., 
or about one-eighth as much as is found in cow's milk, and about 
one-fourth as much as in breast milk. As soon as a tolerance is 
established the quantity is increased about 0.40 per cent, at a time 
until the infant is able to digest whole milk with its 3.20 per cent, 
of protein. These advances in strength of food are made about a 
month apart. There is no fixed rule, except to increase as rapidly as 



PRACTICAL FEEDING. 



167 






the infant can stand it. "With 
some the advance, can be quite 
rapid, while with others it must 
be made slowly. 

By this process the heat 
and energy portions of the food 
are kept up to the highest point 
of efficiency, while the growth- 
producing elements are at first 
given in less quantities than is 
desirable; but gradually they 
are brought up to a point where 
proper tissue formation becomes 
possible. If the protein is given 
in too great quantities at first, 
indigestion results and a period 
of greater or less duration ensues 
in which little growth can be 
made. For this reason it is 
better in the long run to slightly 
underfeed with protein for a 
short time and avoid .digestive 
disturbances. In increasing the 
quantity of protein in the food 
it is often the case that the more 
the haste the less the speed. 

The following table gives an 
outline of the quantities and 
composition of food which may 
be taken as a working basis in 
preparing food for healthy 
infants : 

The whole process of pre- 
paring the food is shown in an 
extract from j^ictorial directions 
for preparing food devised by 
Deming (Fig. 45). For those 
whose minds do not run to 
mathematics a percentage milk 
modifier will be helpful. This 
is a measuring glass graduated to percentages of protein and fat of 
cow's milk. Protein may be varied by 0.20 per cent, at a time and 






Li 





Warm the food 
slightly and give 
1 bottle every 

hours dur- 
ing day. 
times at night 


5 

into each of 
bottles, 
Pasteurize and 
keep on ice. 


4 

Add 
level tablespoon- 
fuls of 

(a] Granulated Sugar 

[b) Milk Sugar 
Stir to dissolve. 



§ 

s 

•a 
5 


llll; 

Li 

lit 

ii 


III ■ 


2 

Take of this 
mixed Top Milk 

dirmerfulR 

or ounces 


o 

« 

m 

o 

_ s 
s 

s 

3 

a 

1 


11 

S c3 

» 2 

o ^ 

fi 

Is. 

Ill 







. Ui 




. 


CO 






CO 


CO 










^ c3 


N 


N 


N 


t4 


N 


N 


SI 










■^ bJb 


O 


o 


O 


O 


O 


O 


o 












HN 


r^ 


-H 


1—1 


^ 


,H]C^ 


rH!(N 




















1—1 


T— 1 








w • 


M U 




m 


m 


m 


CO 


. CO 


CO 










1 

Add 

gruel, 

oz. flou 

to qt 


N 


SJ 


N 


N 


S3 


S3 










O 


O 
O 


O 

CO 


O 
CO 


O, 


o 

CO 








Lh 


T— 1 


(N 


(M 


T— 1 




1—1 










° 


, !h 




m 


CO 


CO 


to 


CO 


CO 










^ S 


N 


N 


N 


N 


N 


S3 


S3 










T3 S) 


o 


O 


O 


O 


o 


o 


o 










<1 in 


1— 1 


C^ 


rH|ri 


H<N 


rH|(N 


iHlM 


-HlM 








<1 ■ 






1— H 


1—1 


1—1 


1—1 


1— 1 






























TS o OP 


m 


CO 


CO 


Xfl 


CO 


CO 










S3 


N 


N 


N 


SI 


SI 










TJ-^ -^-^ 


o 


O 


O 


o 


o 


O 










-=^1? 






o 


CO 


CO 


(N 


CO 








^73 




CNI 


o^ 


T— 1 


1—1 


1—1 












(B 


m 


CO 


CO 


CO 


m 


CO 








O 


O M 


tS3 


N 


Kl 


N 


S3 


SI 


SI 








O 


p^3 


O 


O 


o 


O 


O 


° 


O 








QJ 


rH|?l 


t^ 


(M 


CO 


TtH 


CO 


(M 












(M 




1 — 1 




(M 


CO 


TtH 








03 


cc 


CO 


CO 


CO 


M 


r^ 


^ 




o 


a^ o;^ 


N 


Kl 


S] 


N 


S3 










Remov 

from on 

quart o 

milk 


O 


O 


O 

CO 

T— 1 


o 

o 


o 


0.1 


o'B 

to *^ 






s 


o 






O 


o 


O 






fl 


03 


^ 


6? 


6? 


^ 


^ 


^ 


^ 


^ 




i.2 


ii 


o 


o 


o 


o 


o 


o 


o 


o 






^^ 


«D 


t^ 


t^ 


t^ 


t^ 


1-^ 


t^ 


l:^ 


^ 

^ 




^ 


^ 


^ 


6? 


^ 


^ ' 


^ 


^ 




lO 


o 


CO 


o 

■ 


o 


o 


lO 


O 


•go 




1—1 


CO 


c<i 


CO 


CO 


CO 


CO 


^ 


W) 














' 






.S 

(U 


PL, 03 


'7i 


^ 


g 


^ 


g 


«^ 




^ 


^ 


^1 


o 


o 




o 




o 


o 


o 


o 


TtH 


QO 


(M 


CO 


o 


^. 


oo 


(M 


PC4 


o 


^ 
dn 






^ 


^ 


(M 


c^ 


(M 


CO 


.^ 




















in 






















-+^ 


4^ 


-+i 


C/T-l-S 


~|J 






. 


(U 




^ 


S^ 


^A 


s^ 


^ 


>5 


.>> 


^ >^ 


^ 


bfi^ 


-.^ 


^ ^ 


CO bO 


5 biO 


^bC 


CO c« 


m ci 






sa 


^"3 


^•a 


^•a 


s"a 


^Z 


^73 


CO 


:3^ 


:3^ 


o^ 




^^ 


^ b£) 


G b£ 


O bX) 




O c^ 


O c:! 


A cj 


^^ 


o t^ 


o C^ 


^ a 


'^.a 




£| 






rH|(N QJ 


5s 


CO o 


^1 
CO :3 




ihIm";!! 
CO =3 








^ 
"" 


O 




o 


73 


73 








CO 


CO 




CO 


CO 


CO 


m 






N 


N 




S] 


S! 


SI 


SI 




t/2 


o 

CO 


O 


to 

IS] 

O 


O 

CO 


o 

00 


O 

O 


O 
O 






S3 
O 


-S 


3 


3 


B 


o 


1—1 

o 




B o a^ 


(M 


c^ 


CO 


tH 


T^l 


CO 




-M 




3 N-'-' (N 


1 


1 


1 


1 


1 


1 


00 


00 




^■^ 


Oi 


Ci 


t^ 


t^ 


CO 


CO 


J. 


^ 




^-^ 


oj 


«5 


CO 


CO 


CO 


CO 


CO 


CO 

o 




^J TS 


N 


N 


Kl 


tS3 


S) 


S3 


S3 




•-3 o 


o 


o 


o 


O 


O 


o 


o 






o 


OD 


(M 


(M 


o 


00 


00 


00 




(M 


tM 


CO 


CO 


th 


'^ 


TtH 




o>° 






























A 

-^ 


^ 

rt 


a 
o 


O 

a 














o 


o 

a 

o 


a 






CO 

7:3 


1 


o 

a 


in 
o 

a 


a 

CO 


CM 

rH 
O 


O 






CO 

1 


1 


73 






■^ 


CM 








C^ 


(N 


CO 




t^ 


o 
















^ 




'"' 




i 



, u 

73 oj 

I" 



a o 






OJ CD 



PRACTICAL FEEDING. 



169 



fat in small fractions of 1 per cent. In using it, milk or top milk is 
poured into the graduate up to the figures indicating the desired per- 
centages of protein and fat and the glass is then filled with a diluent. 
The percentage of fat obtained with each percentage of protein when 
whole milk or top milk is used is shown on the glass at the same 
height as the percentage of protein (Fig. 46). By using it a few times 
the physician will quickly grasp the subject of percentage mixtures. 

The modifier is used with a pic- 
torial prescription blank similar to Fig. 
45 which the physician fills out and 
turns over to the mother or nurse. It 
is easy to use in practice and does not 
necessitate any figuring. 

It will be noticed in the feeding 
table that less sugar is to be added to 
the food when gruel is used than v\'hen 
water diluent is employed. This is 
because the gruel contains consider- 
able carboh5^drates. The quantities 
added by gruels will be found in the 
table on page 163. A convenient rule 
to remember is, when gruels made 
with one ounce of flour to the quart 
are used, add 3 per cent, of sugar; and 
when two ounces of flour to the quart 
are employed, add 2 per cent, of sugar. 
These additions would be one thirty- 
third and one-fiftieth of the total quantity of the food, respectively. 
These proportions will always make the percentage of carbohydrates 
in the food between 6 and 8 per cent. 

A rule often employed for adding sugar to food is, add 5 per cent, 
or one part to twenty parts of food. This will always make the 
percentage of carbohydrates fall between 5.5 per cent, and 9.5 per 
cent, when water diluent is used and much higher when gruel diluent 
is employed. One part of sugar to twenty-five parts of food makes 
the percentage of carbohydrates fall between 5 per cent, and 8 per cent, 
when water diluent is used. 

When gruels are used to dilute the milk the percentages of protein 
in the mixtures will be greater than those given in the feeding table 
which are for milk and water mixtures. By referring to the table on 
page 163 it will be found that a mixture made with milk and the gruel 
given above (one ounce flour to quart) will contain 0.82 per cent, protein^ 




Fig. 46. — Deming's percentage 
milk modifier. 



170 DISEASES OF CHILDREN. 

which when made with milk and water would contain only 0.40 per 
cent, protein. The mixture containing 0.80 protein would contain 
1.16 per cent, if the gruel was employed, the 1.2 per cent, mixture 
would contain 1.5 per cent., and the one containing 1.6 per cent, would 
be increased to 1.8 per cent, protein if the gruel was used. The pro- 
tein thus added by the gruel not only increases the tissue-building 
value of the mixtures, but acts as a mechanical diluent or softener of 
the solid formed from the protein of the cow's milk, and hence makes it 
more digestible. As the value of gruels when used intelligently has 
become better appreciated, they have come to be employed more and 
more, and whenever they are tolerated they should be used in preference 
to water for diluting the milk. Two kinds of gruels are employed: 
(a) those made by boiling the cereal in water, which contain starch in an 
unchanged condition ; (h) those to which an agent for changing the starch 
into dextrin and maltose is added. Gruels so made are called, respec- 
tively, plain gruels and dextrinized gruels. Dextrinized gruels should 
be used for young infants and when plain gruels are not well borne. 

Directions for Making Gruels. — Stir from one to four level table- 
spoonfuls of the cereal flour (p. 161) into one quart of cold water to avoid 
the formation of lumps. Place the mixed flour and water into a double 
boiler (Fig. 47) and with constant stirring bring to a boil. This will 




Fig. 47. — Double boiler. 

cause the flour to swell up owing to the gelatinlzation of the starch. 
Now allow the gruel to boil for fifteen minutes. Stirring will not be 
necessary. If an open kettle is used the gruel may burn at the bottom 
and impart a bad taste to the food. If the gruel is to be used plain, 
strain through a fine wire strainer and add enough boiled water to 
make one quart of gruel. If it is to be dextrinized set the cooker into 
cold water for two or three minutes and when the gruel is cool enough 
to taste add a teaspoonful of some preparation of diastase. A de- 
coction of diastase may be made at home by covering a tablespoonful 
of crushed malted barley grains by a little cold water and placing the 
mixture in the refrigerator over night. In the morning the water that 



PRACTICAL FEEDIXG. 171 

is strained off will be active in diastase, but will not keep long. A 
glycerite of diastase known as Cereo is now made for this purpose, and 
has proven to be reliable. Stir and the gruel will become thinner as 
the starch goes into solution and forms dextrin and sugar. Strain 
and add enough boiled water to make one quart of gruel. The floccu- 
lent matter in the gruel is mostly protein. Xo matter which kind of 
gruel is employed it should be cooled and kept on ice until ready to be 
mixed with the milk. 

Adaptation of Food to Infant. — So far the directions have had to 
do only with bringing together the food elements in quantities capable 
of producing proper growth and development at different ages. But 
this is a small part of practical infant-feeding, for any one of the fore- 
going mixtures may not agree with the infant. The problem then 
becomes how to adapt the food so that it will agree with the particular 
infant. Adaptation may be accomplished in a number of ways, 
as follows, beginning with simple changes in the food and ending in 
methods that are more complex in their effects: 

Symptoms. — The infant has no digestive disturbances, except slight con- 
stipation and scanty stools, but does not gain in weight. 

What to Do. — Increase the strength of the food by using the next higher 
formula. 

Symptoms. — The infant vomits, some time after taking its food, rancid- 
smelling material; its stools are soft and contain small flecks or white particles. 

What to Do. — Reduce the amount of fat in the food by using weaker top milk 
or plain milk in making the food. In extreme cases use skimmed milk in making 
the mixture and add a pinch of bicarbonate of sodium to each feeding. 

Symptoms. — The infant's stools are inclined to be too soft, but othervrise it 
seems to be doing well. 

What to Do. — Use barley or wheat in making gruels, and if necessary use 
weaker top milk to reduce fat, which may be excessive. 

Symptoms. — The infant is doing well with the exception of being more or 
less constipated. 

What to Do. — Use oat gruel for diluting the milk as it has a laxative effect, 
and increase the fat in the food to 3.5 per cent to -4 per cent, by using richer 
top milk. Give boiled water between feedings. 

Symptoms. — The infant suffers from colic, but has no curds in the stools. 

What to Do. — Change the form of cereal gruel employed, and dextrinize, if 
plain gruel has been used. That is, if oat gruel has been used, try barley or wheat 
gruel which has been dextrinized in its place. Pasteurize the food temporarily. 

Symptoms. — The infant has colic with more or less curdy stools. 

What to Do. — If water has been used in making the food mixture, try plain 
or dextrinized barley or wheat gruel instead and pasteurize temporarily. If 
this does not overcome the difficulty, add one to two tablespoonfuls of lime-water 
to each feeding bottle; or add one to three grains of citrate of sodium; or add two 
to ten grains of bicarbonate of sodium to each feeding bottle. The effect of these 
additions will be found at page 149. The citrate of sodium or bicarbonate of 
sodium should not be added for long periods, as they interfere with normal di- 
gestive development. 

Symptoms. — The infant has sour, watery stools. 



172 DISEASES OF CHILDREN. 

What to Do. — Reduce the quantity of sugar in the food, as it is fermenting, 
and also change the form in which it is given. If granulated sugar is being used, 
try milk-sugar. If dextrinized gruels are being employed try plain gruels. Pas- 
teurize. In any event change the form of the carbohydrates. 

Food for Infants Previously Badly Fed. 

Feeding History. — These cases almost invariably have a history 
of being well nourished at birth, and perhaps of doing well at the breast 
until for some reason substitute feeding became necessary, when con- 
taminated milk, improper modifications of milk, or proprietary infant 
foods were tried at random, and many or few changes in the food were 
made as method after method failed. These infants may not have gained 
in weight, or if they have gained in weight the flesh produced has been 
fatty, caused by high carbohydrates in the food with low protein. 
They may be suffering from incipient rickets, or show signs of scurvy, 
and in severe protracted cases may have drifted into marasmus. 
Many cases not so severe simply show a loss of weight with the infants 
in a fair condition. 

Management. — When seen early this is the simplest class of cases 
the physician is called upon to treat dietetically, and with careful 
management they promptly respond to treatment, but when the bad 
feeding has been prolonged the cases are often difficult and tedious. 
One of the greatest aids is to work out the composition of food pre- 
viously given, and to consider the methods of adapting the food that 
may have been used, such as addition of lime-water, bicarbonate of 
sodium, citrate of sodium, etc. It is of material assistance to know 
what has failed and whether failure followed a method properly 
carried out or whether it followed incorrect application of correct 
principles. In this connection it may be stated again that the 
physician should understand every detail of the preparation of food 
by all methods, be able to make gruels, should know the physical 
properties of food prepared in different ways, and also be acquainted 
with their taste and flavor. Barley gruel has a slightly bitter taste, 
oat gruel has a distinctive flavor, as has also legume and wheat gruel. 
A gruel that has been cooked in a stew pan often has a scorched taste 
which is sometimes very repulsive. The food may have been kept 
in a warm place or in a poor refrigerator, or the milk may have been 
stale or it may have been partially soured. Occasionally it may be 
found the proper top milk is not being used. These are a few sug- 
gestions which show that no detail of Dreparing the food should be 
overlooked or unknown to the physician. 

For mild cases putting the infant on a formula similar to one 
given on page 168 for healthy infants of the same age will be all that 



PRACTICAL FEEDIXG, 



173 



is necessary, although a very good plan to follow is to give the food 
for a younger infant for a few days and if it agrees a stronger formula 
may then be ordered. 

In more troublesome cases the digestive organs must be given 
a rest, either complete or partial; that is, no food at all must be 
given for a few hours, or the infant must be given not much more 
than enough food to keep it from living on its own tissues. 

The following food mixtures may be tried, using whichever agrees 
best or can be prepared to best advantage, taking into consideration the 
probabilities of directions being carried out properly. 

Dextrinized barley, legume, oat or wheat gruel, made with one to 
two ounces of flour (four or eight level tablespoonfuls) to the quart 
of gruel, directions for preparing which will be found on page 170, or 
whey made as follows may be used: 

Directions for Making Whey. — From a quart of milk remove all 
of the cream. Then add to the skimmed milk a tablespoonful of 
liquid rennet or one junket tablet such as may be had at grocery 
stores. Place the milk in a double boiler (see page 170), and warm 
slowly. When the milk has solidified or "set" cut it in all directions 
into small pieces to allow the whey to escape. Now warm up to about 
150^ F., and stir while doing so. The curd which was all broken up 
will cohere into one or more large pieces which may readily be re- 
moved, and about twenty ounces of clear whey will remain. If the 
whey is heated above 160° F. the albumin will coagulate. The w^hey 
should now be cooled and kept on ice until ready to be fed. Its 
composition will be about, protein 0.80 per cent., fat 0.30 per cent., 
carbohydrates 5 per cent. 

Whey and Cream Mixtures.^In some cases mixtures of whey and 
cream are tolerated better than other forms of food. They may be 
conveniently made as follows: 

From one quart bottle of fresh milk remove with the dipper the top 
6 ounces. Place the remaining 26 ounces in a double boiler, add a tea- 
spoonful of liquid rennet and warm slowly. When the curd has become 
firm, cut it into small pieces with a knife and slowly bring to 150° F. 
Strain through a fine wire strainer, or cheese-cloth, and cool the whey. 

By combining the Avhey and the top 6 ounces removed from the 
quart milk bottle a great variety of mixtures may be obtained as follows : 





Use of the whey. 


Approximate Composition 


Use of the top 6 ozs. 


Protein 


Fat 


Carbohydrates 


1 oz. 

2 ozs. 

3 ozs. 


15 ozs. 
14 ozs. 
13 ozs. 


.80% 
1.00% 
1.20% 


1 .% 
2.5% 
3.3% 


5% 
5% 
5% 



174 DISEASES OF CHILDREN. 

The quantities to be given are a little less than the amount of food 
that would be appropriate for a well infant of the same age. If any of 
these foods are well borne, milk may be added, a teaspoonful to a 
feeding, to see if it will be tolerated, and if so a weak milk mixture 
may be given and the strength of the food increased by degrees untiV 
full strength for the age is reached. If rickets or scurvy is present, 
more care in treatment will be necessary, and this must be according 
to lines laid down under these titles. 

Food for Infants of Feeble Constitution. 

This is one of the most difficult classes of infants the physician 
has to feed, and they often tax his ingenuity to the utmost. They 
are generally the offspring of nervous parents and are easily thrown 
out of equilibrium. They catch cold easily and are subject to attacks 
of indigestion from trivial causes. During the warmer months they 
are readily attacked by gastroenteritis, and their management then 
becomes tedious and their progress is slow, careful watching of the 
feeding being necessary at all times. 

Whenever possible a wet-nurse should be obtained for these 
cases. Artificial feeding is unnatural in all cases, and while it may 
succeed in a majority of instances, its success is due not so much to 
the superior character of the food as to the infant's ability to adapt 
itself to its new food. This power of adapting to environment is 
feeble in these infants of unstable constitution, and too much depend- 
ence should not be placed upon it. Valuable time and strength 
should not be wasted in attempts at finding a food that will agree with 
the infant when it is possible to secure a wet-nurse. At this point it 
will be well to refer to page 109 where the natural place of breast- 
feeding will be impressed upon the mind. 

A Wet-nurse Unobtainable. — When the services of a suitable wet- 
nurse cannot be had, substitute feeding must be tried, and methods 
that at one time would have been looked upon as quite unscientific 
are the ones most likely to give good results. One should not approach 
these cases with fixed ideas of what they ought to take and keep on 
with food that is evidently disagreeing. All of the infants must have 
protein, mineral matter, fats, carbohydrates, and water, and in this 
class of cases it is perfectly justifiable to supply them in any form that 
is acceptable to the infant. Of course, this statement is not to be con- 
strued as meaning any nostrum that may be suggested should be 
tried, but a combination of the food elements that is quite unlike 
either human milk or cow's milk in general composition or physical 
properties, such as given on page 175 may be offered. The point to 



PRACTICAL FEEDING. 175 

bear in mind in the management of these cases is to keep the infants 
ahve and as rapidly as possible build up their strength, and when 
this is done place them on a more natural diet. 

There is more to feeding than combining food elements in 
certain more or less definite proportions. A subtle factor in manag- 
ing these difficult cases is the arousing of the dormant powers of diges- 
tion and assimilation of the infants. This is often accomplished by a 
change in the flavor, taste, or physical condition of the food and in the 
form in which some of the elements are supplied.* So simple a change 
as substituting dextrinized gruel for plain gruel of the same strength, 
in a modified milk mixture, has changed an infant which had worn out 
a family with its digestive troubles into a well-satisfied, contented baby 
in one day. The use of cooked foods, broths, or other forms of food, 
such as egg mixtures or legume gruels, has also brought about sudden 
and permanent improvement. Chemical analysis does not show 
what there is about the food that produces such changes in digestion 
and assimilation, but that different forms of food do hsive different 
effects on different individuals is an undeniable fact, well known to 
animal feeders, who find that by catering to the idiosyncrasies of indi- 
vidual animals, much better assimilation is brought about, and more 
economical use is made of the food. This comes under the head, or 
in the same class, as the fact that food served to an adult in an 
attractive, appetizing manner will be digested much better than if 
it is served in an unattractive, repulsive condition. 

Food for the Acutely 111. 

Classification of Cases. — Under the heading of Acutely 111 it is 
intended to group only those whose illness is reflected in disturbances 
of the digestive organs or by general malnutrition. Infants may 
be acutely ill with pneumonia or other infections and still not show 
special derangement of the nutritional functions. Again, as in gastro- 
enteritis, there is an infection or intoxication which calls for more than 
dietetic treatment, so such cases will be treated under their respective 
titles. 

Management of Cases. — In all of these cases it is of first impor- 
tance to find something that will be retained, and before time is wasted 
in calculating a theoretical^ indicated mixture which may be re- 
jected, it will be best to try some of the following mixtures, which 
if retained, will serve as a starting-point in working up to a suitable 
food mixture. 

1. Dextrinized barley, legume, oat or wheat gruel made 
with one ounce of flour to the quart, as directed on page 170. If any 

* See Catalysers, p. 198. 



176 DISEASES OF CHILDREN. 

one of these gruels agrees, the strength may be increased to two ounces 
of flour to the quart. Such gruels will contain about 0.80 per cent, 
protein and 5 per cent, carbohydrates, except the legume gruel, which 
will contain about 1.5 per cent, proteins with about 5 per cent, 
carbohydrates. 

2. Whey, made as directed on page 173, may be tried, which will 
contain about the same quantities of protein and carbohydrates 
as the gruels made with two ounces of flour to the quart. 

3. The white of one egg beaten up in eight ounces of 
WATER may be retained when nothing else is tolerated. Such a mix- 
ture contains about 1.5 per cent, of protein, but no carbohydrates or 
fat. Its nutritive value is not great. 

4. White of egg and dextrinized gruel, made by beating up 
the white of one egg with eight ounces of dextrinized wheat flour gruel 
(1 ounce to quart) will sometimes agree. If it is acceptable, one to 
two even teaspoonfuls of granulated sugar may be added to the eight- 
ounce mixture, which will then have about the following composition, 
protein 2 per cent, and carbohydrates 6 per cent. 

5. Yolk of egg and dextrinized gruel, made by adding the yolk 
of one fresh egg to eight ounces of dextrinized wheat flour gruel (1 
ounce to quart), and if tolerated adding one to two level teaspoonfuls 
of granulated sugar, is highly nutritious and especially rich in blood 
making substances. If well borne in malnutrition cases legume flour 
may be used in place of the wheat flour. This will increase the quan- 
tity of nucleoproteids in the food materially. 

6. Meat broths oftentimes arouse the appetite, and if acceptable 
may be mixed with dextrinized gruels made with two to three ounces 
of flour to the quart, in equal parts, or they may be thickened with 
the gruel flours' by stirring in an ounce of flour to the quart of broth 
and boiling. This will make a thick broth. 

To make broths, take one pound of lean mutton, veal, or chicken 
with some cracked bone and cut into small squares; add one pint of 
cold water, heat gently, and allow to simmer for about three hours. 
Strain and add enough boiled water to make a pint of broth. When 
cool remove the fat or skim it off while hot. The broth will be gelat- 
inous when cold and should be served warm. 

7. Beef tea is often useful as a digestive stimulant and is made 
by taking a pound of lean beef and cutting it into small pieces and 
allowing it to stand in a pint of cold water for an hour. It is then 
heated to not above 160° F., and the meat is expressed through cheese 
cloth. If heated to above this temperature the albumin of the meat 
will coagulate. If the coagulum is allowed to remain in the tea none of 



PRACTICAL FEEDING. 177 

the nutritive value will be lost, but if it is removed the tea will have 
little but flavor. 

8. Beef Juice is often a useful addition to other foods in cases 
of malnutrition and may be made as follows: 

a. Slightly broil a thick piece of round steak that is perfectly 
free from taint. Cut into small pieces and press in a clean 
meat press or lemon squeezer. 
h. Cut the fresh steak into small pieces and just cover with cold, 
slightly salted water, and set on ice for several hours. Then 
press by squeezing in a piece of cheese-cloth. 
The quantity of beef juice given should not be over one ounce 
in twenty-four hours, and it is given to best advantage when added a 
teaspoonful at a time to other feedings, as in larger quantities the in- 
fant soon tires of it. 

If any of the mixtures just given agrees, attempts at adding fresh 
cow's milk, a teaspoonful at a time, may be made. If the milk is 
tolerated the quantity may be increased cautiously until it forms one- 
fourth of the mixture, when the fats may be increased and the infant 
can be put on a formula suitable for its age as indicated on page 168. 

When All Attempts at Adding Fresh Milk Fail. 

When infants fail to thrive on any of the foregoing mixtures and 
ail attempts at giving fresh milk in any quantity fail, the following 
mixtures may be tried and often are highly successful. Whenever 
the foods that are cooked are used, a teaspoonful or two of beef juice 
or orange juice should be given daily, as on such foods infants are 
liable to develop scurvy. 

Formula Xo. 1. 

Whole milk 12 ounces. 

Wheat or oat gruel flour 4 level tablespoonfuls. 

Granulated sugar 2 level tablespoonfuls. 

Salt 1 pinch. 

Cold water 22 ounces. 

Mix cold and with constant stirring slowly bring to a boil and boil for three 
minutes. Strain and add enough boiled water to make thirty-two ounces. Feed 
quantity appropriate for age. For young infants or very delicate ones the food 
may be diluted with one part of water to two parts of the food. 

Approximate Composition. — Fat, 1.5 per cent.; carbohydrates (starch, milk- 
sugar, cane-sugar); 7 per cent.; protein, 1.5 per cent. 

By using the top 16 ounces from one quart of milk and taking 12 ounces of 
this instead of whole milk in the above mixture the percentages will be: Fat, 
2.5 per cent.; carbohydrates, 7 per cent.; and protein, 1.5 per cent. 

12 



178 DISEASES OF CHILDREN. 

Formula No. 2. 

Whole milk 12 ounces. 

Wheat or oat gruel flour 4 level tablespoonfuls. 

Glycerite of diastase (Cereo) 3 teaspoonfuls. 

Salt 1 pinch. 

Cold water 22 ounces. 

Mix cold and with constant stirring bring slowly to a boil, and boil for five 
minutes. Strain and add enough boiled water to make 32 ounces. Feed quantity 
appropriate for age, or dilute two parts of the food with one part of water for 
very young or delicate infants. 

Approximate Composition. — Fat, 1.5 per cent,; carbohydrates (soluble starch, 
dextrin, maltose, milk-sugar), 6 per cent.; proteins, 1.8 per cent. 

If top 16 ounce milk is used instead of whole milk, the percentage of fat will 
be 2.5 per cent. 

With both of the formulas above it will be better to begin with 
whole milk and increase to top sixteen ounce milk if digestion is good. 

Keller's malt soup is a mixture similar to the above. It is made 
by boiling milk, water, wheat flour, and Loeflund's malt soup extract 
^.ogether. The carbohydrates in the mixture are starch, maltose, and 
^nilk-sugar. 

A few cases may be met in which no food previously suggested 
agrees. In these cases condensed milk, peptonized milk, or buttermilk 
may solve the problem. 

Condensed Milk Mixtures. — Fresh condensed milk is to be preferred, 
but if unobtainable the best brands of sweetened condensed milk 
should be employed. A teaspoonful of condensed milk to four ounces 
of plain or dextrinized gruel may be used at the start. If this is well 
borne, the quantity of condensed milk should be rapidly increased until 
two to four teaspoonfuls to four ounces of diluent are used. Then 
equal parts of cream from bottled milk and condensed milk should 
be mixed and used for dilution, which may be reduced until one part 
of this mixture is used with five parts of diluent, which will give a 
mixture of about the following composition: Protein, 1 to 1.5 per 
cent.; fat, 2 to 3 per cent.; carbohydrates, 6 to 8 per cent. 

Peptonized Milk. Warm Process. — (1) Empty into a clean quart 
bottle the contents of one of Fairchild's peptonizing tubes; (2) add 
four ounces (eight tablespoonfuls) of cold water; shake, and (3) add 
one pint of cool fresh milk and again shake; (4) place the bottle in 
water not too hot to be uncomfortable to the hand for ten minutes. 
Then either place on ice or boil to prevent further digestive action. 
This milk is likely to taste bitter. 

Cold Process. — Prepare the bottle as before, but set on ice without 
warming. This milk is only partially peptonized so will not have a 
bitter taste. 



PRACTICAL FEEDING. 



179 



Buttermilk. — For temporary use buttermilk has a limited field. 
It is best made at home by using one of the lactic acid ferments on the 
market. These consist of lactic acid bacteria which, when placed in 
milk, produce lactic acid from a portion of the milk-sugar, which 
precipitates the casein. Natural buttermilk contains little fat, as 
this has been removed as butter. In making buttermilk the cream 
ma}^ be removed and the ferment added to the skimmed milk, or 
whole milk may be used. 

Two types of buttermilk food are employed. First, the raw- 
buttermilk, which contains enormous numbers of lactic bacteria; 
second, buttermilk to which one ounce of flour (four level tablespoon- 
fuls) is added to the quart, and boiled. Raw buttermilk introduces 
harmless bacteria into the digestive tract which may kill off those 
present that are harmful. Cooked buttermilk supplies a fairly sterile 
acidified food in which the casein is finely divided and cannot form a 
solid mass in the stomach. 

Laboratory Feeding. — In many of the larger cities are to be found 
the Walker-Gordon laboratories at which food for infants is prepared 
upon prescription of the physician. Thej'- were established as the 
results of Rotch's teachings. In their earty days the food was pre- 
pared upon the principle that all differences in milks of different species 
were due merely to differences in percentage composition and in their 
reaction to litmus-paper, and the prescription blank employed was 
gotten up on this basis. 

The Walker-Gordox Laboratory. 



Per cent. 



Remarks. 



Fat 

Milk-sugar 

Albuminoids . . 
Mineral matter 
Total solids . . . 
Water 



100 00 



For whom ordered. 



Date, 



Number of 

feedings? 

Amount at 
each feedings? . . 
Infant's age? . . . 
Infant's weight? 



Signature, 



If the physician does not care to mention the especial percentages, he can ask 
for percentages which will correspond to the analysis of average human milk, and 
he can then vary any or all of these percentages later, according to the need of the 
special infant prescribed for. 



180 



DISEASES OF CHILDREN. 



But with the increase in knowledge of the properties and functions 
of milks of different species, and of the effect of the various additions 
to and manipulations of milk, which made it acceptable to infants, a 
new and broader prescription blank was prepared which is now 
available. 



Fats 

1 Lactose (Milk Sugar) 
Maltose (Malt Sugar) 
Sucrose (Cane Sugar) 
I Dextrose (Grape Sugar) 
[Starch 

(b) Dextrinize 

(c) Proteids ....(Whey 

I Casein 

(d) Peptonize 

(e) Sodium Citrate ... J % of "^'"^ ^nd cream 

I % of total mixture 

(f) Sodium Bicarb. ... j % of milk and cream 

1 % of total mixture 

(g) Lime Water f % of milk and cream 

l % of total mixture 

,.s Lactic Acid P \° inhibit the sapro- 

(n) n .„ J phytes ot fermentation 

^ ^ Bacillus • • • ^, 2 To facilitate digestion 
I of the proteids 



Per Cent. 



Heat at- 



^F._ 



EXPLANATORY 

(a) It requires .75% starch to make 
the precipitated casein finer. 

(b) One hour completely dextrinizes 
the Starch. 

(c) In case physicians do not wish 
to sub-divide the proteids, the words 
"Whey" and "Casein" may be erased. 

(d) Twenty minutes renders the mix- 
ture decidedly bitter. 

(e) It requires 0.20% of the milk 
and cream used in modifying to facilitate 
the digestion of the proteids; i. e., the 
formation of a soft curd. 0.40% to pre- 
vent the action of rennet ; i. e., the for- 
mation of tough curd. 

(f) It requires 68% of the milk and 
cream used in modifying to favor the 
digestion of the proteids. 1.70% of the 
amount of milk and cream used suspends 
all action on the proteids in the stomach. 
.17% of the total mixture gives a mild 
alkaline food. 

(g) It requires 20% of the milk and 
cream used in modifying to favor the di- 
gestion of the proteids. 50% of the 
amount of milk and cream used suspends 
all action on the proteids in the stomach. 
5% of the total mixture gives a mild 
alkaline food. 

(h) Percentage figures represent the 
per cent, of Lactic Acid attained when 
the food is removed from the thermostat. 
When the Lactic Acid Bacillus is used to 
facilitate digestion of the proteids, this is 
the final acidity, as the process is stopped 
by heat at this point. When the Lactic 
Acid Bacillus is used to inhibit the 
growth of saphrophytes, the acidity may 
subsequently increase to a variable de- 
gree, as the bacilli are left alive. .25% 
Lactic Acid just curdles milk. .50% 
gives thick curdled milk. .75% sepa- 
rates into curds and vv^hey. 

WALKER-GORDON LABORATORY CO. 

793 Boylston Street, Boston 
And all Large Cities 

The products of the laboratories, however, are not available for 
the majority of physicians. 



Number of Feedings. 



Amount at each Feedings 



ORDERED FOR 



Addt 



DfltP. 


190 


M n, 


NOTE— See back of pad. 



PRACTICAL FEEDING. 181 

Calorie Feeding. — An attempt has been made to establish a calori- 
metric standard for use in feeding infants^ which at first thought seems 
simple and interesting, but it is based on incorrect principles. A 
Calorie is a measure of heat, being the amount of heat required to raise 
the temperature of one liter of water one degree Centigrade. Heat, 
as is well known, is produced by chemical action, friction, mechanical 
movements, and in the utilization of food by the animal organism. 

It has been determined by experiment just how much heat is 
produced by the oxidation of practically all food substances and 
the burning of different kinds of fuel. In mechanical operations it is 
possible to calculate closely from the amount of heat obtainable from 
any substance the amount of work it can be made to perform. And, 
conversely, to calculate the amount of fuel needed to perform any 
required amount of work. As infants and animals are constantly pro- 
ducing heat and excreting it, by measuring the quantity of the heat 
it becomes possible to determine how much food is required to be 
burned to produce this amount of heat. 

When animals are used to supply mechanical power this process 
of determining the amount of food or fuel necessary is useful, within 
certain limits, but the ease with which the food is assimilated is an 
important factor, for with some classes of foods not one-half of the 
amount of heat the food is capable of producing becomes available, 
the greater portion being wasted in the process of assimilation. In 
selecting food for infants the primary object is not to convert the 
energy content of food into heat, but to supply materials from which 
blood, muscle, and bone can be constructed. 

An ounce of food containing 

1 per cent, fat yields 2.S Calories 

1 per cent, proteins yields 1.23 Calories 

1 per cent, carbohydrates yields 1.23 Calories 

and if the amount of heat the food would supply was all that determined its 
suitability for infant-feeding it would make no difference if the food was all fat or 
proteins or carbohydrates. 

A mixture which is much used in feeding infants contains protein I per cent, 
fat 3 per cent., and carbohydrates 6 per cent. By multiplying the percentages, 
of each ingredient by the number of Calories each per cent, will yield, it will be 
found that one ounce of this mixture yields seventeen Calories. The following 
formulas show a few mixtures of widely differing composition, each of which 
yields seventeen Calories to the ounce: 

■ ^ I \ \ ^ I n r \ 

Protein 0. 5% 1 .0% 1 . 5% 2. 0%J2. 5% 3 .0% 3 . 5%|2. 0%:3.0%!3 .0% 

Fat 3.0% 3.0%l3.0%|3.0% 3.0% 3.0% 1 .0%'l . 5%|l .5%i2.0% 

Carbohydrates . . .6 . 5% 6 . 0%|5 . 5%l5 . 0% 4 . 5% 4 . 0%'8 . 0% 8 . 0%o|7 . 0%,'6 . 0%, 

^ I \_ \ ' i 

In practice these formulas would not be interchangeable, although from the 
calorimetric standpoint they are equally valuable. 



182 DISEASES OF CHILDREN. 

As infant-feeding centers around a supply of protein, and the well- 
being and development of the infant depend absolutely upon a suffi- 
cient supply of this element of food, the standard is being modified 
to include the principle that a certain proportion of the food be com- 
posed of proteins. 

The amount of heat an infant will excrete will depend upon the 
character of its food, and the season of the year. Food that is 
difficult of digestion causes more heat to be excreted than easily 
digested food, and sometimes gain in weight can be made on a 
smaller quantity of easily digested food when no gain is made on a 
much larger quantity of food that requires more digestive effort. 
In hot weather the infant does not need food to supply heat, as it has 
no need for it, and is constantly excreting surplus heat produced by 
its mechanical movements. Under certain conditions the whole suc- 
cess of managing infants during the heated term depends upon re- 
ducing the amount of heat it produces, and food that produces 
little heat is given, or none at all, and the infant is sponged to aid in re- 
moving the heat unavoidably produced. 

In practice the calorimetric standard will be found to possess no 
advantages over the standards generally used except possibly as a 
check on the total quantity of food. 

Directions for the Mother or Nurse. 

Education of Mother Necessary. — One of the greatest aids in the 
feeding of infants artificially is intelligent cooperation of the mother, 
and it should be explained to her that as she would naturally feed the 
infant until its digestive organs are sufficiently developed to digest 
soft table food, (Fig. 26 page]09),itis her duty to become acquainted 
with the details of preparing and administering artificial food. Time 
expended in teaching a mother how to prepare food and why the differ- 
ent processes are used will be well spent and will eventually repay the 
physician. 

The mother or nurse should be shown just what she is expected to 
do. Directions should be written out. The feeding schedule on page 
168 may be followed as a general guide as to what the formulas for 
different ages should be and the pictorial directions (page 167) when 
shown to a mother will make things clearer than long explanations. 

Care of Food. — When a good, clean milk cannot be obtained, 
or when the conditions are such that the food after being prepared 
cannot be kept below 50° F., it should be pasteurized. The fact that 
the food is kept in a refrigerator does not necessarily mean that it is 



PRACTICAL FEEDIXG. 



183 



kept cool, as the temperature in some refrigerators is above 60° R 
The food should be kept surrounded by ice. 

Nursing bottles of the style shown in Fig. 48 should be used, as 
they can be readily cleaned. After the food is placed in them they 
should be stoppered with clean absorbent cotton. Corks should 
not be used, as the milk gets into the pores and sours, or otherwise 
spoils and infects the next feeding. 

If the food is to be pasteurized the Freeman pasteurizer (Fig. 49) 
or Arnold Sterilizer (Fig. 50) may be used, or when these are not avail- 




FiG. 48. — 
Nursing bottle, 
preferable. 




Fig. 49. — Freeman pasteurizer. 



able a home-made pasteurizer may be employed (Figs. 51, 52). This 
is made from a six quart tin pail. A false bottom is made by punch- 
ing holes in a tin pie plate which is then inverted in the pail. The bot- 
tles of food or irAlk are placed on the false bottom, and water is poured 
around them up to the level of the milk. The pail is then placed on a 
stove and the water brought to a temperature of 165° F., as determined 
by a thermometer. The pail is now covered with a cloth and removed 
from the stove, and allowed to stand for half an hour. A folded news- 
paper is a good thing to stand the pail on as it will prevent too rapid 
loss of heat. After standing half an hour the food or milk should be 
cooled by placing it in cold water, until thoroughly cooled, otherwise 
the bacterial spores which are not destroyed by pasteurizing will 
germinate and may cause disturbance of the infant's digestive tract. 
Old pasteurized milk should never be used. Fresh food should be 
made every day. 



184 



DISEASES OF CHILDREN. 



Administration of Food. — Regularity in feeding should be in- 
sisted upon. The food should be slightly warmed by placing the bottle 
in warm water for a few minutes. Night feedings should not be 




Fig. 50, — Arnold sterilizer. 



warmed before retiring and kept warm. This is a pernicious 
practice. The cotton stopper is then removed and a black rubber 
nipple should be placed on the bottle which should be inverted to 
see that the hole in the nipple is large enough to allow the food to 



^ 




A 



A 



"- 



A 




WW' 




Fig. 51 — Home-made 
pasteurizer. {Russell.) 



Fig. 52. — Pasteurizer for bottled milk. 
(Russell.) 



drop slowly, but not so large as to permit the food to run in a stream. 
The mother or nurse should be cautioned not to put the nipple in her 
mouth. By allowing the food to drop on the wrist it will be possible 
to determine whether it is too hot or too cold. 




PRACTICAL FEEDING. 185 

The infant should not be over twenty minutes in taking its 
food, and if satisfied will drop off to sleep. Never use the food that 
may be left in the bottle, but throw it away. If a considerable 
portion of the food is left in the bottle the nipple should 
be examined to see if the hole is too small or has become 
clogged. 

Care of Utensils. — After preparing food the dipper, 
double boiler, bottles, spoons, and all articles that have 
been used should be washed, first wdth cold water, and 
then with soap or washing compound and hot water, and 
then scalded. The bottles should be cleaned with a 
brush (Fig. 53), and after being scalded should be kept 
inverted until ready to be filled again. The nipples 
should be thoroughly washed and kept lying in a cup of 
water in which a good-sized pinch of borax has been 
dissolved. 

Examination of Stools. — The mother should be 

taught to examine the stools and to report to the physi- 

Bott?e brash ^^^^ ^^^ appearance of anything abnormal, as change of 

color, diarrhea, the appearance of curds or of mucus. 

The mother should not be taught that these are alarming symptoms, 

but that they indicate something is wrong and needs attention. 

How to Interpret Results. 

Weighing the Infant Important. — Infants should be weighed at 
regular intervals in about the same clothing, as steady gain in weight 
is one of the indications that they are thriving on their food. But 
judging the value of a food by the mere fact that it causes gain in 
weight is quite wrong as the gain may be only in fat. 

The composition of the food, (see page 164), the general develop- 
ment and gain in weight should be taken into consideration, and no 
infant should be dismissed until its food contains considerably over 
one per cent, of protein and it is gaining in weight on it. 

The gain in w^eight is greatest in proportion during the first few 
months, as food is assimilated more completely at this period, as has 
been explained on page 154. Just how much an infant should gain 
each week cannot be stated definitely, as infants vary in this respect. 
Some will gain a pound and others not over two ounces, but the latter 
gain is too small for a healthy infant. Six ounces is a good gain. If 
the food is agreeing the quantity or strength maj^ be increased cau- 
tiously to see if greater gain will result, but this plan must not be pushed 



DISEASES OF CHILDREN. 



to an extreme, for loss instead of gain may result. A record of the 
weight should be kept on a weight chart, according to the plan shown 
in Fig. 55. Weight charts have been prepared on which is shown 
the '^normal weight curve" deduced from the average gains of a 
large number of infants. It is better not to use this style of weight 
chart, as few infants pass their first year without some ups and downs, 
and the slightest variation from the '^normal curve" is a cause of 
worry and anxiety to the mother and through her to the physician. 




Fig. 54. — Wei2:hino; the infant. 



Feeding in Hot Weather. — Upon the advent of hot weather special 
precautions should be taken to forestall attacks of gastroenteritis. 
The means for keeping the food cool should be looked after, and tested 
with a self-registering thermometer, or the food should be kept packed 
in ice to make sure it is kept cool. Pasteurization may be necessary 
if ice is not available. If the infant has a tendency to indigestion or 
to vomiting, the amount of fat in the food should be reduced by using 
whole milk instead of top milk in making the food. One or two feed- 
ings of gruel used as the diluent may be put up, and given as night 
feedings or as substitutes when milk feedings seem to disagree. 

If the air is humid and the temperature high, the infant should 
be given a sponge bath twice a day. The excess of body heat is ex- 
creted by the evaporation of perspiration, and this is retarded by high 



PRACTICAL FEEDING. 



187 



humidity. And unless the skin is kept clean and free from the residue 

from the evaporation of perspiration, this will also retard evaporation. 

Feeding when Traveling.— Changes in the food are risky at any 

time and especially so when traveling. A good plan to follow is to have 



WEIGHT IN GRAMS. 



cJS^'oooiooSSot, SiSSiSSi^^ScoS?^^ 




«^_ 


1 1 III III Mi 1 1 1 j M III il : : I 1 1 : : 1 M ill ill 1 1 I : 1 1 1 , II III III 


^ 




"" 


1 Ml ! 1 ' Ml 1 ' ' ' 1 ' ' 1 ' ' ' ' ' ' ' ' ' ' 1,1 ' ' ' 1 ' < 1 II ill II 


ss" 


■ i 1 ' ' ' 1 ■ 1 1 ■ ■ ■ ■' ' ' ' ■ ■ ' ■ ' i 1 1 i 11 1 1 




1 ! i . ■ 1 i 1 : : 1 > 1 , . i • ' 1 ^ ' ■ : : : : ' 1 1 1 1 1 ! 


o 






1 1 h 1 li 1 1 1 1 1 1 i 1 1 M - 1 I i 1 i 1 M : . 1 i 1 ' 1 1 ' i 1 ' i ' 1 , 1 1 1 1 1 


t'° 




^„ 


Vf .•' h: ,:, ill ^ ; ,,. . /. . ' :■ ■ -^ In III 1 






to 


1 r 1 ' 1 i ■ 1 : 1 j 1 , , 1 i , , ' ' ! - M i I ! 1 1 


S''° 






1 - i 1 1 ^ > . .' 




1 1 1 II i 1 1 . Il 1 i i 1 1 1 1 




II 1 i 1 . ' " III 1 1 1 


55 ■" 


III 1 1 III, 1 , . M i 


'-',0 


1 1 1 1 1 I 1 1 1 1 




1 M 1 1 1 M M 




i 1 1 1 1 II 1 1 1 1 1 


«" 


II 1 II 1 1 1 1 1 II 1 1 1 M 1 II 1 11 1 


''n 


1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 II 1 




J_ 1 ± _L_L 11 1 1 ± 1 ± ± Jj 1 




.. \ \ 1 1 1 __ 1 J 1 _ 1 _, ! _ 1 ^IL 1 


<»^ 


1 1 1 1 1 1 1 1 1 1 1 I 1 1 II 1 1 1 1 1 1 1 1 1 1 


^ 


1 II III 1 1 1 I l| II 1 M 1 il 1 1 1 1 1 1 1 1 M 1 1 : 1 1 1 




II III II 1 ll 11 1 1 1 i 1 1 1 11 1 1 1 1 1 1 i 1 1 1 


■* 


II 1 1 II 1 1 1 1 1 1 1 II 1 II 1 1 M 1 1 1 1 1 1 




II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 M 1 1 1 1 1 1 1 i 1 


■^ 


1 1 1 1 1 1 1 1 1 1 1 1 1 M 1 1 1 1 1 1 1 II 1 II 1 




1 II 1 III III 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 II 1 1 1 II 1 1 1 1 1 


'S' 


II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 { 1 1 1 1 1 1 1 1 1 1 1 1 


CO »' 


II II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i 1 1 1 1 1 1 1 1 


i^^c 


II j 1 1 1 1 1 1 1 1 1 1 M 1 1 1 1 1 1 M 1 1 1 1 1 1 1 i 1 1 1 M 1 1 1 1 


liJ s 


II II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 II 1 1 1 1 1 1 1 1 1 1 M III 1 


UJ ^ 


1 III 1 1 1 1 1 1 M 1 1 M |l 1 1 1 1 1 1 1 1 1 1 1 1 II 


^«" 


II 1 11 1 1 1 1 1 1 1 III 1 1 11 1 1 1 1 II 1 


z s 


II 1 II 1 1 1 1 1 1 1 III M 1 1 1 1 i 1 1 




Il III 1 1 III II II 1 II III 1 III 


u " 


II III 1 II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 M 1 1 1 . 


a si" 


1 1 1 1 1 III III 11 


< "- 


1 1 1 1 1 1 1 1 1 1 1 1 




^^1 ^ ^ -- if-- M T 


" 


1 11 1 1 1 1 1 1 1 i 1 1 


«- 


11 1 1 II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 


<»'. 


1 III 1 1 1 1 1 M 1 1 III II 




1 1 1 1 1 1 1 IN 1 III II 




1 1 1 1 II 1 1 II 1 


•^'^ 


II 1 1 1 1 ' 1 \ 1 I 1 1 1 1 1 M ' ' 1 t 1 1 




1 1 1 1 1 i i \.i 1 1 1 1 1 1 III 1 1 


" 


II 1 1 I 1 \l 1 ll 1 1 1 1 




II 1 1 iN^i 1 1 1 1 


0" 


1 II i 1 1 M >vi 1 1 1 


"^a. 


1 MM 1 1 M 1 II ?s; 1 1 II 1 1 M M 1 




III 1 1 11 1 1 II \i 1 M I 1! 1 M 


— 


II 11 1 1 II ■ 1 1 1 1 \ M ■ . 1 1 j 1 


«- 


1 II 1 1 1 1*^. M M 1 




1 i II M i i 1 \ll M 


~ 


1 1 11 1 1 II 1 i \i II 


— 


II 1 1 1 1 1 1 II II 1 1 M liV M 




1 11 III M M M^ ,1 II 




1 1 _L_L 1 XL 


"" 


T 4 T 1 1 V 




"1 T I I 


O) 


_L. r ± ^ 




1 M 1 1 I \ 


'^ 


Mil 1 1 i 1 ! > 


to 


, : M , : 1 J , i < 


■" 


• 1 il ■ i , 1 1 i 1 1 l\ 


■^ 


1 M : i i : j i 1 M , 1 M V 




1 1 M M 1 1 1 1 1 ' , 1 M 1 : 1 ' \ ■■ 1 




■ ■ 1 M 1 i ! 1 1 1 ' ! ■ 1 ■ ■' ■ M 1 M M ■ N 1 




1 III 1 1 1 1 1 1 M 1 M i ' ' 1 1 ■ ■ 1 ' M ■ 1 ' 1 M / 1 1 


t 


;s; :?!: ;^ » ^ :5t ;?; ;,x: ;^ it ;5t -^ ^ i>t ^ ist^s^ii^s:^]::^ ;=t :s: ;5?i» ;sti:s: s;i>;^t|;s: ^^i;^;is:i;5s::stiit:s?|;:Rs:|^^t»^ » 



■SQNnOd Nl 1H0I3M 



the regular food prepared and packed in ice to insure thorough cooling 
and then to place it in vacuum bottles, such as the Thermos (Fig. 56). 
The bottles should be filled right up to the stopper, otherwise the agi- 
tation of the food will churn the milk so that the fat will separate as 



188 



DISEASES OF CHILDREN. 



butter. Several of these bottles will be required if the journey is to 
last several days. If there is a question about the food being kept cool, 
it should be pasteurized, then cooled or iced if possible, before being 
put into the vacuum bottle. These bottles while expensive will be 
found useful to those who can afford them. They will keep food cold 
for about seventy-two hours. 

The food for the infant can be poured from the vacuum bottle 
into a clean nursing bottle and warmed as wanted. But the food 
should be slightly shaken so as to mix the cream 
which will have risen to the top with the remaining 
milk. The food should not be warmed and then 
kept in one of these bottles to save warming. Milk 
soon spoils if kept warm. 

For a single day's journey the food may be put 
up as usual in the home and boiled and then iced 
and, when cold, wrapped in newspaper, each bottle 
being wrapped separately; or the food may be put 
in a pail with cracked ice around the bottles, which 
is preferable. 

When it is not possible to have the foregoing 
directions carried out, one of the best brands of 
sweetened condensed milk diluted with boiled water 
may be used. The boiled water may be carried if 
it will not be obtainable during the journey. 

Feeding when Away from Home. — During the 
heated term large numbers of families leave the 
cities and live in the country at boarding houses, 
hotels, or in their own homes. In many of the more 
remote districts the milk-supply problem has not yet been solved and 
much disturbance may be caused by milk which has been improperly 
handled through ignorance. 

In such instances the mother should make an arrangement with 
some milkman or farmer to supply milk produced under sanitary con- 
ditions. The farmer should be instructed to clean the cows as thor- 
oughly as he cleans his horses, to wipe the belly and udder with a 
damp cloth before milking, to wash his hands before milking, and to 
reject the first two or three jets from each teat. The milk pail should 
be well washed and scalded after being used and kept inverted in the 
sun. As soon as the milking is finished the milk should be mixed, as 
it is not uniform in composition as it leaves the cow, and then poured 
into quart milk bottles. These should be set in ice-water, or if this 
is not obtainable, into cold w&ll water which rises nearly to the tops 




Fig. 56. — Thermos 
vacuum bottle. 



PRACTICAL FEEDING. 189 

of the bottles. The milk can be delivered in the morning in time to 
prepare the food for the day. 

Such milk will cost more than the ordinary milk, but it is worth 
all it costs, and will be found cheaper in the end. The mother should 
see for herself that the milk is produced under cleanly conditions. 
She would not tolerate a filthy wet-nurse for her infant and should not 
allow her infant's food to come from a filthy cow. 

Feeding Amoiig the Poor. — The preparation of food or even 
obtaining suitable food materials is often a perplexing problem among 
the poor and in the tenements of large aities. The intelligence of the 
mother may be limited and even when the mother is capable of carry- 
ing out directions the facilities for preparing food and keeping it 
cool are wanting. Some families are too poor to buy clean bottled 
milk at ten cents a quart and oftentimes such milk is not offered 
for sale in the poorer sections of a community. 

Correct dietetic principles must be applied as best the}^ can be. 
Where good milk can be obtained, but careful modification cannot 
be expected, the food may be made with whole milk and gruel, using 
one-fourth, one-third, and one-half milk and 'adding one part of 
granulated sugar to thirty-three parts of food, or two level table- 
spoonfuls to the quart of food. 

Where good milk is unobtainable, condensed milk may be used 
with water or barley gruel made with one ounce of flour to the quart. 
The milk should be diluted 8 to 15 times, that is, one part of condensed 
milk to 7 to 14 parts of water or gruel. No sugar is to be added. 
Cod-liver oil or olive oil can be given daily, one teaspoonful three times 
a day to supply the fats. 

Infant's Food Dispensaries. — The unsatisfactory results obtained 
in infant-feeding among the tenement population, owing to improper 
preparation of food or lack of suitable food, has led to the establish- 
ment of food dispensaries in the crowded sections of many cities. 
There are three types of these feeding stations: (1) Those at which a 
few formulas of modified milk may be obtained in nursing bottles by 
anyone who applies for them, no supervision of the cases being made. 
(2) Those at which fixed modifications of milk are given out by trained 
nurses or physicians who examine the applicants and aim- to give a 
formula which is likely to agree. (3) Those at which the food is 
prepared for each infant while it waits, upon the prescription of the 
attending physician. 

The feeding stations at which food is dealt out without taking into 
consideration the condition of the infant are not to be encouraged, for 
while they do much good, they also do harm. 



190 DISEASES OF CHILDREN. 

Where the infant-feeding problem among the poor is handled on a 
large scale and physicians who have not had wide experience in feeding 
infants and in the actual processes of preparing food see the patients, 
the second type of feeding station will be most successful. For these 
stations the food is prepared at a central station on a large scale and 
delivered iced to the local stations, where the mothers bring their babies, 
and the physician or nurse in attendance examines them and orders a 
food mixture. The formulas given on page 168 may be followed closely, 
and if the infants are not acutely ill, digestively, beginning with a weak 
mixture and going from this to stronger ones will be found quite satis- 
factory. During the heated term feedings of plain and dextrinized gruels 
made with one to two ounces of barley or oat gruel flour to the quart 
should be kept on hand to be given when milk feedings disagree; for 
infants that are quite sick they may be diluted once with boiled water. 

Making Feedings on a Large Scale. — To those who are not familiar 
with methods of handling milk it sometimes becomes a difficult 
matter to work out the proper quantities of ingredients to use to get 
the desired formulas. 

By referring to the key on page 160, the required percentage of 
fat in milk and the proportion of diluent to use to obtain any desired 
percentage combination will be found. Thus, if a mixture containing 
0.80 per cent, protein and 1 per cent, fat was desired, it would be 
found necessary to use milk containing 4 per cent, fat with three parts 
of diluent. If 1.5 per cent, fat was desired with 0.80 per cent, protein, 
it would be necessary to use milk containing 6 per cent, fat with three 
parts of diluent. 

On a small scale these milks can be readily obtained from quart 
milk bottles, but when large quantities are to be made the milks must 
be standardized. 

The milk should be obtained from a farm where cleanliness is 
observed, and it should be kept cool until delivered at the central 
station where the food is to be prepared. A sample which represents 
the entire lot should be drawn, by dropping a long tube or pipet 
through the milk from top to bottom so as to remove a sample that 
represents the entire can. 

This is then tested by the Babcock milk test, which consists of 
mixing a definite quantity of the milk with sulphuric acid in a special 
bottle and then whirHng it in a centrifuge. Great heat is produced 
which melts the fat. The protein dissolves and the percentage of fat 
is read directly from the neck of the test bottle. The milk should 
also be tested with lime-water and phenolphthalein (page 150) to 
see if souring has commenced. 



PRACTICAL FEEDIXG. 191 

A certain amount cf cream or skimmed milk will always be needed. 
If a centrifugal separator is available, they can be obtained by centri- 
fuging the milk. Otherwise the cream must be skimmed by hand 
from a can of the whole milk. The cream and remaining milk will 
also have to be tested for fat. Knowing the percentage of fat in the 
whole milk^ cream, and skimmed milk, it becomes necessary to calculate 
the quantities to mix to make any standardized milk. 

To Increase the Amount of Fat in Milk. 

1. Determine the quantity of standardized milk to be made, it may be 
pounds, quarts, or gallons. 

2. Multiply the quantity of standardized milk by its percentage of fat. 
Example, 100 pounds of 6 per cent, fat milk, 100 X 6 per cent. = 600 per cent. 

3. Multiply the desired quantity of standardized milk by the percentage of 
fat in the whole milk as determined by the Babcock test, as, for example, 100 pounds 

X 4.7 per cent. = 470 per cent. 

4. Subtract the amount of fat in the quantity of whole milk from the amount 
of fat in the desired quantity of standardized milk, to find how much fat must 
be added, as 600 per cent. — 470 per cent. = 130 per cent. 

5. Determine the percentage of fat in the cream, as, for instance, 21 per cent. 

6. Subtract the percentage of fat in the whole milk from the percentage of 
fat in the cream to find how much fat one part of cream contains in excess of that 
in the whole milk. Example, 21 per cent. — 4.7 per cent. = 16.3 per cent. 

7. Divide the additional fat required by the amount one part of the cream 
adds to find how many parts of cream must be used. As, 130 per cent.H-16.3 
per cent. = 8 parts. 

8. Thus 8 pounds of cream, 21 per cent, fat, and 92 pounds of milk, 4.7 per 
cent, fat, make 100 pounds of 6 per cent, fat milk. 

Proof: 8 X 21% = 168% 
92 X 4.7% = 432% 
100 600% or one part = 6%. 

To Decrease the Amount of Fat in Milk. 

Proceed as in 1, 2, and 3 above. Then divide the percentage of fat in the 
total quantity of standardized milk desired by the percentage of fat in the whole 
milk. For example, 100 pounds of milk containing 3 per cent, fat were needed, and 
the whole milk available contained 4 . 7 per cent. fat. 100 X 3 = 300. 300h-4.7 per 
cent. = 64 pounds. By adding to this quantity 36 pounds of skimmed milk 
there will be produced 100 pounds of milk containing 3 per cent, of fat. If the 
skimmed milk contain not over 0.5 per cent, fat, the result will be accurate enough. 

After standardized milks are made, great care must be exercised 
in keeping the feeding bottles clean and in washing them, for all the 
care employed in preparing the milk may be rendered useless by water 
used in washing bottles, as this may be infected and produce a high 
bacterial count in the food. 



192 DISEASES OF CHILDREN. 

Feedings Prepared at the Feeding Station. — When a physician who 
thoroughly understands the preparation of food can have a good 
nurse to carry out his directions and with only two rooms, one to be 
used as a kitchen and the other as an examining room, highly sat- 
isfactory results can be obtained. The physician can examine the 
infant and order any kind of food prepared, and the nurse will prepare 
it while the mother waits. The food is put up in nursing bottles and 
given to the mother in a box or pail filled with cracked ice. By using 
bottled milk and the Doming Milk Modifier, percentage mixtures can 
be quickly made. Gruel mixtures, whey, or whatever is desired can 
also be made. One nurse can attend to about thirty infants in a 
morning. 

Approximate Home Modification of Whole Milk. 

Since there are some localities in which bottled milk is not obtain- 
able, it is well for the practitioner to know how he can approximately 
modify the milk when he can only assure himself that the supply is 
wholesome and obtained under cleanly precautions. 

In many isolated farming districts bottled milk is out of the 
question, and it is impracticable to have it delivered in bottles. Spe- 
cial utensils as the Chapin dipper are not ready at hand or the mother 
may be deemed too unintelligent to use them correctly. 

The principles of percentage feeding can sometimes be carried 
out and good results obtained by using very simple measures. This we 
have demonstrated to our satisfaction in our City Milk Depots where 
mothers in the tenements have been taught to modify whole milk with 
success as far as the health and growth of their infants was concerned. 

We have never believed that success depended upon fractional 
percentages but rather upon percentages approximately correct made 
up with a pure wholesome milk and fed to a baby that is kept under 
the proper hygienic conditions as outlined in Chapter IV. 

The physician should be careful to select a milk from a mixed 
herd of cows and if possible avoid a milk apt to be too rich in fats, such 
as would be obtained from Jersey cows. If there is any question as to 
the richness, an examination can be made, at the nearest creamery, of 
the fat content and computations can then be based on this analysis. 

The average whole milk will contain fat, 4 per cent. ; sugar, 4 per 
cent.; protein, 3.2 per cent. If such a milk is diluted four times, that 
is, one part milk and three of diluent, we will have 
Fat. Sugar. Protein. 
4 I 4 4 3.2 ' 

^ 1 0.8 



PRACTICAL FEEDIXG. 193 

1 per cent, fat, 1 per cent, sugar, and 0.8 per cent, protein in the 
mixture. This needs but the addition of sugar to make a suitable food 
for an infant up to the third month of life. The quantity and time of 
feeding will be found on page 168. Enough sugar is added to make 
6 per cent.; the amount is easily calculated if it is recollected that 1 
ounce of cane sugar to every 20 ounces of the food will add 5 per cent. 

Similarly if a dilution of three parts is made, that is, one part milk 
and two of diluent, we would have fat 1 1/3 per cent., sugar 1 1/3 per 
cent., protein 1 per cent., and again if the whole milk is diluted once, 
we have fat 2 per cent., sugar 2 per cent., protein 1.6 per cent. If 
three parts of milk are in the mixture and one of diluent its composi- 
tion will be fat 3 per cent., sugar 3 per cent., protein 2.4 per cent. 

If there is any question as to the cleanliness of the milk or the 
healthfulness of the cows, the milk may be pasteurized, especially in 
hot weather, if refrigeration is not available. 

The following are simple modifications of raw whole milk made 
up with water or barley gruel (see p. 170) and reduced to the quantity 
to be taken at each feeding. 

Baby three days to two weeks old, feed every two hours. 

Milk, 1 tablespoonful. 

Water or barley water, 3 tablespoonfuls. 

Sugar, half a teaspoonful. 

Baby two weeks to three months, feed seven to eight feedings 

every two hours. 

Milk, 2 tablespoonfuls. 

Water or barley water, 4 tablespoonfuls. 

Sugar, 1 teaspoonful. 

Baby three to six months old. 

Milk, 6 tablespoonfuls. 
Barley water, 6 tablespoonfuls. 
Sugar, 2 teaspoonfuls. 
Six such feedings in the twenty-four hours. 

Baby six to nine months old. 

Milk, 12 tablespoonfuls. 
Barley water, 6 tablespoonfuls. 
Sugar, 2 teaspoonfuls. 
Give five such feedings in the twenty-four hours. 

Baby nine to twelve months old. 

Milk, 16 tablespoonfuls. 
Barley water, 4 tablespoonfuls. 
Sugar, 2 teaspoonfuls. 
Give five such feedings in the twenty-four hours. 

Catalysers. 

That a mere change in the flavor or form of food oftentimes 
produces a remarkable improvement in the assimilation of nourish- 
13 



194 DISEASES OF CHILDREN. 

ment has long been known to investigators in the field of animal nutri- 
tion, as well as to many physicians, and the most striking results in 
difficult infant-feeding cases have come from the application of this 
principle although this fact has not always been recognized. 

Until recently, however, there has been no satisfactory explana- 
tion of this phenomenon, but experiments made to discover simpler 
processes of manufacturing certain chemical products, which could 
only be obtained by indirect methods, have brought to light a factor in 
chemistry whose importance hitherto had not been suspected, and 
which explains this peculiar effect on assimilation of a change in the 
form and flavor of foods. 

An illustration from actual experience will make the matter clear. 
It has long been known that certain chemical products can not be 
produced by merely bringing together their constituents in proper 
proportions. A mixture having the same chemical composition as 
the desired product can be obtained but no chemical combination is 
produced. However, the presence of some extraneous substance may 
cause the chemical combination to take place, although this substance 
does not enter into the combination, remains unchanged, and can be 
used repeatedly for this purpose. 

Such substances are known as catalysers and a quantity so small 
as to be not detectable by chemical analysis is oftentimes all that is 
needed to cause certain chemical combinations to take place that would 
not occur in their absence. Now, these catalysers may become 
poisoned and lose their efficiency, and then either a new supply of the 
same catalysers must be had or a different one must be employed, for 
different substances may have the power to cause the same chemical 
combination to take place. 

After foods have been digested they must be absorbed and 
then combined chemically to form the tissues. The materials neces- 
sary to form the tissues are well known, but how to make them com- 
bine is not known. There are undoubtedly catalysers in the organism 
which cause the chemical combinations to take place and malnutri- 
tion is probably the result of their absence or of their being poisoned. 
A change in the character of the food may stimulate their production 
or present forms of food that they can cause to combine. The 
remarkable results obtained in industrial chemistry with catalysers 
in producing substances which have heretofore been obtainable only 
by the action of living substances, seems to indicate that catalysts 
play a great part in nutrition. 



CHAPTER XVII, 

DIET DURING THE SECOND YEAR. 

By the beginning of the second year the infant's digestive organs 
should be sufficiently developed to warrant giving some soft food. 
The greatest amount of trouble will be caused by cereals which are 
not properly cooked. Fig. 57 shows a cross 
section of an oat grain. It will be observed 
that the protein and carbohydrates are in- 
closed in cells. These are composed of cellu- 
lose which is indigestible, and they must be 
ruptured by cooking before the digestive 
secretions can get at their contents. Fig. 58 
shows what takes place when cereals and 
vegetables are cooked properly and too much 
emphasis cannot be laid upon the importance 
of thoroughly cooking cereals. Oatmeal par- 
ticularly should be cooked in a double boiler 
several hours. Flours do not need such long 
cooking. 
The following schedule has been arranged as a suggestive scheme 
for the feeding of older normal children: 




Fig. 57. — Section of oat 
grain, c, protein layer; 
d, starch and protein. 
(Goodale.) 




Fig. 58. — Rupture of starch grains by cooking. {Langworthy .) 

Many children are indiscriminately fed, and the physician being 
unfamiliar with the kind of food suitable and agreeable to the child 
neglects to suppl}^ directions as to the dietary. Changes should be made 

195 



196 DISEASES OF CHILDREN. 

in the list if there is illness, habitual constipation, or difficulty in digest- 
ing certain forms of food. It should be recollected that the child can be 
trained to like almost every suitable article, and it is a mistake to cater to 
their likes and dislikes if they are not developing and gaining weight. 
Under their respective sections changes in the character of the 
food have been suggested where they have any bearing on the progress 
of the disease. 

Dietary. 

Twelfth to Eighteenth Month. — Select from the following articles : 
First meal — on arising. 

Juice of a sweet orange, one to two ounces. 

Pulp of six stewed prunes. 

Pineapple juice, one ounce. 

Milk, eight ounces, zwieback, toasted biscuits (as Huntley 

& Palmer's), stale toasted bread. 

Second meal — during forenoon. 
Milk alone or with zwieback. 

Noon meal. 

Soup made of chicken, beef, or mutton, six ounces; or beef 

juice three ounces. Stale or toasted bread may be added to 

the above. 
Fourth meal — afternoon. 

Milk, or toasted bread and milk. 
Evening meal. 

Gruel made of oatmeal, farina or barley, taken with whole 

milk, four ounces of each. 

Apple sauce or prune jelly. 

Zwieback. 

Eighteenth to the Twenty -fourth Month. 

Breakfast. 

Juice of one sweet orange. 

Pulp of six stewed prunes. 

Pineapple juice, one ounce. 

A cereal, such as cream of wheat, oatmeal, farina, or hominy 

preparations with top milk (top 16 oz.). Sweetened or saltedo 

A glass of milk. 

Forenoon. 

A glass of milk with two toasted biscuits or zwieback. 



DIET DURIXG THE SECOXD YEAR. 197 

Dinner, 

Broth or soup made of beef, mutton, or chicken and thickened 

with peas, farina, sago or rice; or beef juice with stale bread 

crumbs; clear vegetable soup with yolk of one egg; or egg, 

soft boiled, with bread crumbs, or the egg poached. 

A glass of milk. 

Dessert. — Apple sauce, prune pulp, stale lady-fingers, or 

graham wafers. 

Supper. 

Custard. Cup of milk warm or cold. Stewed fruit. Zwie- 
back. 



Two to Three Years. 

Breakfast. 

Juice of one sweet orange; pulp of six stewed prunes. 

Pineapple juice, one ounce, or apple sauce. 

A cereal, such as oatmeal, farina, cream of wheat, hominy, 

or rice, slightly sweetened or salted as preferred, with the 

addition of top milk (top 16 oz.); or a soft-boiled or poached 

egg with stale bread or toast. 

(If there is a tendency to constipation give the fruits before 

breakfast with water; if not, they may be given during the 

forenoon if preferred.) 

A glass of milk. 

Dinner. 

Broth or soup made of chicken, mutton, or beef thickened 

with arrowroot, split peas, rice, or with the addition of the 

yolk of an egg or toast squares. 

Scraped beef, white meat of chicken, broiled fish (halibut is 

free from bones). 

Mashed or baked potato, fresh peas, spinach, asparagus tips. 

A glass of milk with educator crackers, Huntley & Palmer 

biscuits or graham wafers. 

Dessert. — Apple sauce, baked apple, rice, junket, or custard. 

Slipper. 

Stewed fruit. 

A cereal or egg (if not taken for breakfast); bread and milk; 

or custard; cup of warm milk or cocoa; crackers or zwieback. 



198 DISEASES OF CHILDREN. 

Three to Six Years. 

Breakfast. 

Fruits. — OrangeS; cantaloupe, apples, or stewed prunes. 
Cereal or eggs (not both). Oatmeal, hominy, rice and wheat 
preparations, well cooked and salted, as described on page 
195, with thin cream and sugar. 
Eggs. — Soft boiled, poached. 
Milk. — Milk or cocoa to drink. 

Dinner. 

Soups. — Beef, chicken, or mutton. 

Meat. — Chicken, beefsteak or roast beef, fish. 

Vegetables. — Spinach, carrots, string beans, peas, cauliflower 

tops, mashed or baked potato, asparagus tips. 

Bread and butter (not fresh bread or rolls). 

Dessert. — Custard, rice or bread pudding, tapioca, ice cream 

(once a week), prune souffle, or baked apple. 

Milk. 

Su'p'per. 

Milk toast, or a thick soup, as pea, or cream of celery, or a 
cereal and thin cream. Stewed fruit, custard or a plain pud- 
ding graham crackers and milk. 

Suggestive Diet List Suitable for Children's Hospitals. 

Monday. 

Breakfast. — Oatmeat, bread and butter, milk. 

Dinner. — Beef soup, chicken, mashed potatoes, bread and butter, 

corn starch pudding, milk. 
Supper. — Bread and butter, milk, apple sauce. 

Tuesday. 

Breakfast. — Eggs, bread and butter, milk. 

Dinner. — Chicken soup, chicken, mashed potatoes, bread and butter, 

rice pudding, milk. 
Supper. — Bread and butter, milk, stewed prunes. 

Wednesday. 

Breakfast. — Hominy, bread and butter, milk. 

Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, 

bread pudding, milk. 
Supper. — Bread and butter, jam, and milk 



DIET DURING THE SECOND YEAR. 199 

Thursday. 

Breakfast. — Eggs, bread and butter, milk. 

Dinner. — Beef soup, chicken, mashed potatoes, bread and butter, ice 

cream, milk. 
Supper. — Bread and butter, jam, and milk. 

Friday. 

Breakfast. — Oatmeal, bread and butter, milk. 

Dinner. — Mutton broth, roast mutton, mashed potatoes, bread and 

butter, custard pudding, milk. 
Supper. — Bread and butter, milk, apple sauce. 

Saturday. 

Breakfast. — Homin}^, bread and butter, milk. 

Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, 

chocolate pudding, milk. 
SujDper. — Bread and butter, milk, stewed prunes. 

Sunday. 

Breakfast. — Oatmeal, bread and butter, milk. 

Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, 

ice cream, milk. 
Supper. — Bread and butter, milk, jelly. 

Suggestive Diet Lists for Day Nurseries and Creches, 

Group 1 (Bottle-weaned babies) 

Milk (whole milk), warm or cold, 8 ounces. 

Farina gruel with milk and sugar, zwieback. 

Beef or mutton soup, thickened with toast crumbs. 

Orange juice, 1 ounce. 

Apple sauce. 

Prune pulp. 

Amount needed daily — three meals — 24 ounces milk, 10 ounces 

soup, zwieback, 2 pieces, fruit, one kind. 

Group 2 C'Ilunabouts")« 

Milk. 

Zwieback or toast, or stale bread. 

Soft-boiled egg. 

Farina, cream of wheat, oatmeal. 



200 DISEASES OF CHILDREN. 

Soup, beef or mutton thickened with spHt peas, rice, or 

farina. 

Baked potato, mashed potato, carrots, beets. 

Custard, cornstarch, farina pudding, apple sauce, prune 

jelly, or apple butter. 

Amount required daily, three meals, 36 ounces of milk, one 

cereal, one vegetable, one soup, bread, one fruit. 

Group 3 (Kindergartners — two meals). 

Bowl of crackers and milk, farina, oatmeal. 

Beef or mutton stew. 

Eggs, soft-boiled or scrambled. 

Mashed potato, peas, carrots, beets, cauliflower. 

Rice pudding, cornstarch pudding, baked apple, apple sauce, 

prunes. 

Amount required, three cups milk, soup, vegetable, bread 

and butter, cereal or pudding. 

Group 4 (School age). 

Noon. 

Soup, beef or mutton. 

Beef or mutton stew. 

Potato (mashed), spinach, carrots, or beets. 

Bread and butter. 

Pudding, farina, rice, cornstarch. 
4 p. M. 

Milk, cocoa. 

Bread and butter, jam. 

Raw apples. 

Diet During Later Childhood. 

The period of growth from early childhood to puberty requires 
careful oversight of the nutrition. The child must be regularly trained 
in all the hygienic details of feeding, including slow eating and the 
avoidance of strenuous exercise just before or after eating. The diet 
requires a large amount of protein owing to the rapid growth, and this 
must be supplied principally by the ordinary meats (beef, mutton, 
and chicken) and such vegetables as peas and beans. All the cereals 
will also supply some protein with a large amount of starch. The 
heat- and energy-producing foods (starches, sugars, and fats) may be 
supplied in the form of potatoes, cereals, fruits, and fats from milk 



DIET DURING THE SECOND YEAR. 201 

or meat. It is very desirable to train the child to take a varied and 
properly balanced diet, which includes all the foods in common use. 
Thus if very much meat is taken to the exclusion of carbohydrates, 
the protein will be employed too largely in oxidation to produce body 
heat instead of in building tissue, and hence grow^th may be retarded. 
A certain amount of the carbohydrates acts as protein sparers, and 
thus allows the protein to be used entirely in its proper function of 
building tissue. This is an example of the desirability of a properly 
balanced diet. The green and succulent vegetables and fruits also 
have an important function in nutrition, as is seen in cases of scorbutus 
where there has been a long deprivation of these articles of diet. 
Lesser degrees of malnutrition result if they are not taken in proper 
amount. 

The two usual cycles of grow^th, namely at the second dentition 
and adolescence, require an especially generous diet. Rapid growth 
always uses up nutrient material and hence calls for food rich in 
protein, otherwise various grades of anemia are liable to result. 

Dietary Suitable for Children After the Sixth Year. 

Soups. — Beef broth, chicken broth, mutton broth, oyster broth, bou- 
illon, milk soups, purees of vegetables, legumenose soups. 

Vegetables. — Peas, carrots, spinach, baked potato, mashed potato, 
stewed potato, celery, string beans, lima beans, beets, beet-tops, 
rhubarb, squash, pumpkin, lettuce, endive, stewed tomatoes. 

Eggs. — Soft-boiled, poached eggs, scrambled eggs, omelet (plain). 

Sea Food. — Raw oysters, steamed oysters, boiled fish, broiled fish. 

Meats. — Beefsteak, roast beef, roast chicken, minced chicken, boiled 
chicken, broiled chicken, roast mutton, roast lamb, lamb chop, 
turkey, squab, sweetbreads. 

Farinaceous. — White bread, whole wheat bread, graham bread, corn 
cake (not hot), gems, toast, plain crackers, educators, zwieback, 
farina, cream of wheat, oatmeal, rice, hominy, macaroni -(plain), 
spaghetti (plain). 

Fats. — Cream, butter, olive oil, peanut butter. 

Beverages. — Milk," top milk, buttermilk, cocoa, matzoon. 

Dessert. — Stewed fruits, baked custard, bread pudding, corn-starch 
pudding, rice pudding, tapioca pudding, junket, plain cake, ice- 
cream. 

Fruits. — Raw apples, baked apples, apple sauce, stewed prunes, 
stewed figs, pears, peaches, grapes, oranges, grape-fruit, melons, 
strawberries, raspberries, blue berries, blackberries. 



SECTION V. 
DISEASES OF THE DIGESTIVE SYSTEM. 



CHAPTER XVIII. 
DISEASES OF THE MOUTH. 

General Considerations. 

It is very essential that the normal condition of the mouth be 
preserved in infancy, as the act of sucking may be impaired and thus 
result in malnutrition of the infant. The mucous membrane of the 
mouth is particularly delicate, and bacterial invasion follows readily 
any injury to its surface. Even well-meant but too vigorous cleansing 
by the attendant may lead to serious mouth disease. Not until the 
teeth are present should any special effort be made to cleanse the oral 
cavity. The primary teeth should receive regular attention, and the 
aim should be to preserve them as long as possible, and thus ensure a 
vigorous and well-formed permanent set. A soft tooth-brush, used 
with an up-and-down, movement, will effectively cleanse the teeth from 
adhering particles of food, especially if the child learns to flush or 
gargle the mouth after its use. 

The nodules formed near the raphe in infants are normal cystic 
bodies called epithelial pearls, and must not be considered pathological. 
We have seen harm done by measures used for their removal. 

Desquamative Glossitis. 

(Geographic Tongue. Ringworm of the Tongue.) 
The above headings apply to a condition of the tongue in which 
there are areas sharply circumscribed by sinuous borders. The bor- 
ders are made up of enlarged papillae of a dull grayish color which tend 
to intensify the denuded areas. Numerous microorganisms of a low 
order are found especially in the borders of the patches. The varia- 
tions in the outlines have given rise to the term ^'geographical tongue." 
It is found among all classes of children; it can only occasionally be 
associated with the derangement of the digestive tract. It gives no 
symptoms, and is productive only of alarm to the mother. It is most 
commonly seen in children under three years of age. 

Treatment. — The mother should be reassured as to its unimpor- 
tance. Nitrate of silver, J dram to the ounce, applied with a. cotton 
swab and neutralized with a salt solution has seemingly arrested the 

202 



DISEASES OF THE MOUTH. 203 

process in a few cases. In others it has persisted for months, only to 
finally disappear spontaneously. 

Simple Stomatitis. 

{Catarrhal Stomatitis). 

Simple stomatitis is an inflammation of the mucous membrane of 
the mouth; with the characteristic symptoms of pain, redness, and 
swelling, and an increase in the normal amount of secretion. 

Etiology. — It is mainly observed in the first year of life, and re- 
sults from some form of irritant, which may be chemical, mechanical, 
or thermal in its nature. Among those commonly causative are im- 
properly prepared food, thumb or nipple sucking, and too vigorous 
mouth washing. Excessive use of carbohydrates, especially cane- 
sugar, may be a cause, and the disease is occasionally an accompani- 
ment of prolonged fever due to intercurrent maladies. 

Symptomatology. — The babe refuses to take its nourishment or 
has pain while taking it. This should direct attention to the mouth. 
There is marked drooling, and on inspection, redness, swelling and 
congestion of the mucous membrane are apparent. The tongue may 
be more or less coated. The temperature, if elevated at all, is not 
high. There is no adenitis. The restlessness and irritability point to 
a constitutional involvement. 

Treatment. — The affection tends to a spontaneous recovery, es- 
pecially if the causative factor is removed. After a few days there 
is restitution to normal conditions. Prophylactic treatment embraces 
the constant care and cleanliness of everything coming into contact 
with the child's mouth. On the other hand, we have observed the 
inflammation following well-meant but too vigorous mouth cleansing. 
Local applications hasten recovery. A 1 per cent, solution of nitrate 
of silver may be brushed over the surface by the physician once a day, 
and a 2 per cent, solution of boric acid is swabbed on every two 
hours by the attendant. 

The following is an excellent and soothing lotion for all forms of 
sore mouth: 

I^ Sodii sulphis ' oj 

Glycerini 5ss 

Aquae rosse q.s. ad. oij 

M. Sig. — Paint over the tongue and inside of the 
cheeks every two or three hours with a camel's-hair 
brush. 

Order the food diluted one-half and given cold. If the nipple is 

refused in an artificially fed baby, feed with the spoon or dropper. 

It is rarely necessary to resort to gavage. 



204 DISEASES OF CHILDREN. 

Aphthous Stomatitis. 

{Herpetic StomatitiSy Aphthce, Follicular Stomatitis, Vesicular 
Stomatitis, Maculo fibrinous Stomatitis.) 

Definition. — A disease characterized by isolated yellowish-white 
spots on the lips, mouth, or palate, surrounded by a reddened mucous 
membrane. 

Etiology. — No specific exciting cause has as yet been firmly estab- 
lished. The weight of evidence seems to point to an infective rather 
than to a neurotic origin, since clinically we have found its spread 
possible through communication. Lack of proper cleanliness is the 
cause in the great majority of cases. Most of the attacks occur dur- 
ing the second year of life; and we have in addition to uncleanliness 
of the mouth and utensils, the direct dirt infection produced by the 
crawling, hand-sucking infant. It is also seen occasionally in connec- 
tion with such diseases as pneumonia, gastroenteritis, or the infectious 
diseases proper. 

Lesion. — The superficial mucous membrane shows a fibroplastic 
exudate in a localized area, having a reddened areola. The process 
does not go on to ulceration, the mucous membrane healing without 
scar formation. 

Symptomatology. — Before the lesions are observed it may be 
noted that food is refused or taken with discomfort by the infant. 
The pain causes irritability and disturbed sleep. There is sometimes 
a low febrile reaction. The breath is not foul. The saliva flows 
freely. After a few days the glands beneath the jaw may be somewhat 
enlarged and painful to the touch. Inspection shows a number of 
whitish spots, which sometimes coalesce, on the lips, cheeks, or palate, 
surrounded by a red ring. The pseudomembrane cannot be removed 
without exciting some slight bleeding. 

Course and Prognosis. — The affection lasts abcut a week and tends 
to recovery. With proper treatment the course is considerably 
shortened. 

Treatment. — Prophylactic. This embraces all that was said 
under simple stomatitis, and may be stated in one word — cleanliness. 

Local. — The early apphcation of a 2 per cent, solution of silver 
nitrate, once or twice daily, shortens the disease and makes the infant 
much more comfortable. A 2 per cent, solution of chlorate of potash 
may be applied by the attendant three times a day with a brush. 

General. — A dose of castor oil is usually indicated and helpful. 
The diet should comprise cool milk or gruels until the discomfort has 
disappeared. 



DISEASES OF THE MOUTH. 205 

Bednar's Aphthae. 

These are superficial ulcerations which occur in the new-born or in 
early infancy on either side of the palatine ridge at the hamular 
process. They are usually the result of traumatism caused by too 
energetic cleansing or the sucking of artificial nipples. This portion 
of the mucous membrane is normially thin and tightty-stretched, and 
therefore easily abraded. Not infrequently these ulcerations are seen 
following thrush. They are usually bilateral, about the size of a small 
bean, and are covered with a grayish-white necrotic coating which 
cannot easily be washed away. Nursing is interfered with on account 
of the pain they cause. 

Treatment. — Prophylactic. — The proper care of the infant's mouth 
(see p. 203) and the early treatment as in thrush. 

Locally. — The application daily of a 2 per cent, solution of silver 
nitrate, which is neutralized by salt solution, will readily effect a cure. 

Perleche. 

This is an ulcerative process superficial in character which 
appears at the angle of the mouth of children of school age. 

Radiating fissures first appear at the corners of the mouth which 
are brownish-yellow in color, and soon become covered wdth desqua- 
mating epithelium. A gummy exudate contracts the angles which 
readily bleed if stretched. Licking the lips, no doubt, infects these 
areas, and prevents healing. Contamination to others in the family is 
occasionally observed. 

Treatment. — Proper advice as to contact infection by kissing, 
food utensils, etc., is to be given. 

Locally, the area is thoroughly cleansed and swabbed with silver 
nitrate 2 per cent, or burnt alum. An antiseptic powder such as 
bismuth subgallate may then be applied. 

Mycotic Stomatitis. 

{Parasitic Stomatitis, Thrush, Sprue, Soor, White Mouth.) 

Definition. — This is a local mouth disease produced by the growth 
of a specific cryptogamic fungus. 

The affection occurs most frequently in early infancy. The 
children of the poor, because of parental ignorance or neglect, are 
prone to the disease. Badly or improperly fed infants are subject 
to this affection because of the greater liability to uncleanliness in the 
feeding apparatus. Marasmic and atrophic infants seen in hospital 



206 DISEASES OF CHILDREN. 

and dispensary practice, seldom pass through the first few months of 
life without contracting the disease. 

Specific Cause. — Under the microscope a small particle of the 
growth appears as a matted fungus microorganism, made up of 
shreads, composed of jointed filaments. Spores are found at the 
junction of the filaments, which reproduced the growth. This par- 
ticular fungus has not as yet been properly classified. 

Symptomatology. — Small rounded white masses appear on the 
mucous membrane of the mouth. The tip of the tongue, and next the 
cheeks and gums are affected. In exceptional instances remoter 
areas of the gastrointestinal tracts, as the esophagus and stomach, 
are involved. 

As the masses fuse, the characteristic appearance, i.e., a whitish 
coating resembling milk curd, is seen in the mouth. 

The masses, if an attempt is made at removal, come away with 
difficulty, leaving a reddened surface beneath. As the disease pro- 
gresses, the infant has difficulty in feeding and will be restless and 
peevish. There is rarely any constitutional disturbance or rise of 
temperature. Occasionally there will be concomitant irritation of 
the alimentary tract with the production of vomiting and abnormal 
stools. If the reaction of the mouth be taken with litmus-paper it 
will invariably be found acid in reaction. Exfoliation of the pellicles 
take place after a week or ten days, leaving the mucous membrane 
reddened and glistening. 

Course and Prognosis. — The affection lasts from a few days to a 
week at the most. The exceptions appear in infants with constitutional 
diseases in which thrush appears as a complication; in these it may 
persist for a long time or add to the fatality of the case. 

Treatment. — Prophylactic. — Thrush does not appear in those 
infants who have been properly cared for. The essential prophy- 
lactic measures are constant supervision and great cleanliness of the 
infant's utensils, which should be boiled and kept for the one infant 
only; washing the mother's nipples, avoidance of harsh mouth wash- 
ings, removal of soiled clothes and diapers, and absolute restriction 
of all manner of comforters or soothers. The diet must be carefully 
regulated, as infants suffering from this disease have nearly always 
been wrongly fed. (See section on Infant Feeding.) 

Local. — Swab with a 2 per cent, or a saturated solution of boric 
acid (avoid the honey and boric preparations), three or four times 
a day, and follow with copious washing of sterile water. This is 
curative and soothing. In stubborn cases swab once with a weak for- 
malin solution (1-100) and then use the boric wash. Sodium sul- 



DISEASES OF THE MOUTH. 207 

phite dram one to two ounces of water may be used after each feeding. 
If the nipple is refused, feed with a dropper for a few days. 

Ulcerative Stomatitis. 

{Stomacacoe, Putrid sore mouth.) 

Etiology. — This form of stomatitis is found after the second year 
of life, when the teeth have erupted and caries or neglect of the teeth 
has taken place. It follows the infectious diseases, especialty measles, 
and results from the lowered resistance that the previous disease has 
imposed. Bernhem and Pospisil have isolated a bacillus and a spiro- 
chete, which they find quite constantly in ulcerative stomatitis, and 
they have been able to prove a distinct etiological relation. Minerals, 
such as mercury and phosphorus, are able to produce an ulcerative 
stomatitis through their irritative action. 

Symptomatology. — Attention may be attracted to the child be- 
cause food is refused and pain is caused by attempts at eating. The 
breath is foul. The tongue is coated. The children are irritable and 
sleep poorly. There is a loAv-grade temperature. They become weak 
and depressed from lack of food. The examination of the mouth shows 
the gums at first to be swollen and red. The lower jaw is commonly 
involved at some point situated on the edge of the gums. A purulent 
exudate is then formed that goes on to necrosis and the formation of 
an ulcer. As a rule, the preliminary stages are not observed. An 
ulceration on the gum margin which spreads even to the buccal por- 
tion of the gum is the usual picture. In aggravated cases the tooth is 
exposed and loosened in its socket. The odor is distinctly fetid and 
quite characteristic of this form of mouth disease. Drooling is pro- 
nounced. The cheek and lips may also be involved by contact, and 
even necrosis of the jaw may follow in the pathological process. The 
neighboring lymph-glands become hypertrophied. 

Course and Prognosis. — The prognosis depends greatly upon the 
vitality of the child. In poorly nourished, anemic children, it may 
run an obstinate course of several weeks. As a rule, it begins to clear 
' up after the first week. 

Differential Diagnosis. — The almost typical picture, with the fetid 
breath, salivation, and localization on the gums, stamps the disease 
quite clearly. In gangrenous stomatitis we have marked and early 
constitutional symptoms and prostration, with a limited dark, pur- 
plish area of tissue involved. 

Treatment, Local.^The mouth should at once be carefully flushed 
with a mild antiseptic, such as boric acid or peroxid of hydrogen well 



208 DISEASES OF CHILDREN. 

diluted. Remove the offending carious tooth if present, and then use 
chlorate of potash locally (and also internally, see below), four grains 
to the ounce, applied carefully with a brush or cotton applicator. 
Silver nitrate in a 1 per cent, solution locally, is serviceable, if the 
process is obstinate. If necrosis of bone has taken place, surgical 
intervention is necessary and should not be delayed. 

General. — The nutrition should be rigidly kept up and detailed 
feeding lists supplied. Milk and eggs made palatable (see diet 
lists) should be forced if necessary. An antiscorbutic diet, such as 
is described under infantile scorbutus is particularly serviceable in 
these cases. Medicinal treatment is confined to the use of the chlorate 
of potash in 2- to 3-grain doses, three or four times a day. It is better 
not to write for more than a three-ounce mixture, as the potash may 
affect the kidneys if given for too long a period. 

Gangrenous Stomatitis. 

{Noma, Cancrum oris.) 

Definition. — A rapidly developing and usually fatal gangrene, 
beginning in the cheek. 

Etiology. — No specific organism has as yet been satisfactorily 
proven as the causative agent. The disease occurs in children only, 
most often between the ages of two and five years and rarely in nurs- 
lings. Children living in bad hygienic circumstances that have had 
their resistance much lowered by previous diseases, especially those 
that have been confined to hospitals and asylums, are more prone to 
the affection. It may follow measles, diphtheria, typhoid, ulcerative 
stomatitis, scarlet fever, enteritis, pneumonia, pertussis, tuberculosis, 
etc. The greater number of cases occurring in this country have 
followed severe cases of measles, and in the epidemic form in institu- 
tions, it may there even follow mild cases. 

Symptomatology. — A putrid odor from the mouth may be the 
first symptom to attract attention. Inspection may then disclose a 
stomatitis as a forerunner. In other cases there is first observed a 
swelling of the cheek, which is hard, shining, and pallid. Pain is not 
caused by the examining finger. The inner surface of the cheek may 
show the original site of the infiltration and at this point an ulceration 
is observed. The submaxillary glands if not as yet affected soon 
hypertrophy. The infiltrated area in the cheek now becomes dark 
red, and soon is bluish and later black in color. The fetor increases. 
A line of demarcation now appears about the dark area and spreads 
upward to the eye and outward toward the ear. A punched-out 



DISEASES OF THE MOL'TH. 209 

area soon appears, permitting inspection into the mouth. The gums 
are correspondingly affected^ being covered with greenish-gray slough. 

The periosteum may be separated. The teeth are loosened or 
even drop out. There is seldom any bleeding because the process is a 
gangrenous one. The stench is now almost intolerable. 

As may be supposed the general condition soon suffers from such 
a destructive process. The pulse and temperature are elevated — 102° 
to 104° F. — with a correspondingly weak pulse. 

While at first nourishment is taken and little pain complained 
of, soon the patient succumbs and is badty prostrated. Signs of 
exhaustion are apparent. Patches of bronchopneumonia or a 
diarrhea complicate the disease. A comatose condition with septic 
rises of temperature usher in the fatal ending. 

In certain cases in female infants the necrosis involves the vulval 
ring which may soon completely slough out. 

Course and Prognosis. — The course is rapid; the disease may end 
in a week or it may last three weeks from its inception. Onl}^ 15 per 
cent, of the cases recover (Moro). Those that do live are left with 
severe deformities of the face. 

Treatment. — Strict attention to the nasopharyngeal toilet in the 
infectious cUseases will tend to prevent this affliction. 

The early and complete extirpation of the diseased area and 
cauterization of the edges is the modern treatment adopted by the 
surgeons, and the results achieved warrant its recommendation. 
Wherever possible, attempts should be made to save the angle of the 
mouth to prevent a disastrous deformity. Loosened teeth or necrotic 
alveolar structure should be removed. 

Meanwhile, the internist will flush the mouth with a 2 per cent, 
solution of peroxid of hydrogen, or swab with a 5 per cent, solution of 
nitrate of silver, followed by salt solution. 

Nourishment should be forced and stimulation in the form of 
brandy and strychnia given. Turpentine spirits, if kept near the 
patient, will mitigate the nauseating odor. 

Elongated Uvula. 

Although rarely observed, this condition has led to much improper 
medication for persistent cough. The elongated uvula irritates the 
pharynx and causes a cough which is especially m.arked when the 
prone position is assumed or when the child is overtired. If the 
chest is negative, this condition should be thought of. Treatment is 
by astringents, applications of silver nitrate, but usually amputation 
is indicated and necessary. 

14 



CHAPTER XIX. 
DISEASES OF THE DIGESTIVE TRACT. 

Corrosive Esophagitis. 

Etiology. — This condition is caused by the swallowing of caustic 
chemicals, such as potash and sulphuric acid, which produce corrosive 
burns of the esophagus. Lye is the most common substance ingested 
by children. The lesions vary. There may be a.n intense acute inflam- 
mation, a necrosis of the mucous membrane, or extensive ulcerations 
which produce cicatricial strictures in healing. 

Symptomatology. — If much caustic has been swallowed, death 
may shortly result; otherwise there is prostration and vomiting of 
shreds of bloody mucus, or even pieces of mucous membrane may be 
expjelled. The child cannot swallow without pain. An erosive hemor- 
rhage may occur after a day or two, or a deep-seated cellulitis may 
result with infection. A stricture is very likely to develop in severe 
cases. 

Treatment. — Appropriate antidotes are to be given if the patient 
is seen early; such as the acids or the alkalies, depending on the 
character of the poison. The prostration must be combated by 
supportive treatment, hypodermatic injections of camphor or strych- 
nia. For the intense pain, codein subcutaneously will be indicated. 
Olive oil thrown into the esophagus is a distinct advantage, and if 
the child can swallow, this should be regularly administered. The 
treatment of the stricture is surgical. The string method has given 
some brilliant results in cases coming under our observation. Gas- 
trostomy may be necessary to preserve the life of the child if sudden 
occlusion of the esophagus results. 

Congenital Occlusion of the Esophagus. 

This condition is rarely observed. Difficulty in swallowing and 
the regurgitation of the smallest quantities of food should lead to an 
investigation with the bougie. The atresia or stricture is usually 
situated at or near the bifurcation of the larynx, 

210 



DISEASES OF THE DIGESTIVE TRACT. 211 

Acute Gastric Indigestion. 

{Acute gastritis, acute dyspepsia, acute gastric catarrh.) 

Etiology. — Errors in diet are the principal cause. In infancy the 
quality and quantity of the milk, or the irrational use of extraneous 
articles added to the dietary act as causes. Improper feeding habits 
will bring on occasional attacks. Sweets, unripe fruits, and pastries in 
older children or even large quantities of one kind of food may produce 
an attack. Usuall}^ there is more or less involvement of the intestinal 
tract. 

Symptomatology. — The symptoms very often begin suddenly 
with fever, headache, abdominal pain, and vomiting. The temperature 
may reach 104° F. with a correspondingly high pulse rate. The 
vomiting is repeated several times, and the evidences of undigested 
food, or a certain article of food which has caused the attack, as unripe 
fruit, are seen therein. The patient is chilly at times and apt to be 
sleepy-. Food is abhorent, the tongue is coated with a thick fur, and 
the breath is disagreeable. Occasionally convulsions occur, especially 
in neurotic children. After the vomiting has ceased or a (compen- 
satory) diarrhea has set in, there is relief from the distressing symp- 
toms, although nausea and vomiting may reappear if the child is 
pressed to eat. 

Prognosis. — This is usually very favorable, although the onset of 
convulsion in a weakty infant would warrant a guarded prognosis. 

Treatment. — In breast-fed infants, examine the mother's milk, 
and give plain boiled water until vomiting and fever have subsided; 
a cleansing enema will complete the cure if the milk is not perma- 
nently abnormal. Bottle-fed infants suffer often from this malady, 
and the food formula and its preparation should be inquired into 
most minutely, for well-intentioned attendants often make griev- 
ous errors. Calomel gr. i in divided doses every ten minutes will 
clear the bowels. If there is a convulsion, clean out the bowels at once 
with an enema and later wash out the stomach if vomiting has not been 
free. In all cases the patient should be put to bed, without a pillow, 
and a mustard paste applied to the epigastrium in the strength of one 
to seven of flour. The fever is controlled by sponging with alcohol and 
water. Dietetic management is very important. Infants may be 
kept on albumin water, cereal decoctions, or whey, and then gradually 
returned to their regular feedings. Older children are not allowed to 
take any food for twelve to twenty-four hours, except sips of cold 
water. Then beef tea, toast, and crackers are allowed and later milk, 
milk toast, etc., slowly returning to the regular diet. 



212 



DISEASES OF CHILDERN. 



Gastric Ulcer. 

While this disease is not of frequent occurrence during childhood, 
it may happen at any period of life, even during infancy. Stowell 
has collected thirty-five cases from birth up to puberty, the earliest 
at five days, and six during infancy. 





^ 




..^^^ 


*"" '^ 




:v. 


■dH^^^i, '.i^^^^l 


^^ 




''%.- 




1 

L. 


-,<-'w««....*^^ " 





Fig. 59. — -Ulcer on lesser curvature: infant 7 months old. 



Etiology. — The following conditions may act as causes: Hyper- 
acidity of the stomach with spasm of the pylorus, swallowing sharp 
substances with resultant local injury, various infectious diseases and 
septic conditions following birth, extensive burns, thrombosis of the 
umbilical vein and embolisms in the stomach wall. 



DISEASES OF THE DIGESTIVE TRACT. 213 

Pathology. — In young infants there may be melena, usually from 
sepsis, and blood may be passed in the stools presenting a dark ap- 
pearance from iron sulphid produced from the hematin of the hemo- 
globin. The ulcer may be located in any part of the stomach but is 
most commonly situated in the lesser curvature. In cases that per- 
forate, the site is most often on the anterior wall. 

Symptomatology. — During infancy the principal symptom may 
only be a constant gastric irritation and indigestion with occasional 
hematemesis, or the vomitus may simply be streaked with blood. If 
there is sufficient blood to pass into the bowel, dark, coffee ground 
masses may appear in the stool, f Vomiting, however, is not such a 
constant symptom in early life as in adults./ Pain is a fairly uniform 
symptom: *It is aggravated at once by taking food, especially sugary or 
rich preparations, and relieved by vomiting. Pain can also usually 
be elicited by firm pressure over the stomach. • The imperfect diges- 
tion and disinclination to take food soon result in progressive emacia- 
tion. Constipation is often present and profound anemia may result if 
healing does not soon take place. If perforation or severe hemorrhage 
occurs, there will be the usual symptoms of marked collapse. 

Diagnosis. — This must depend upon constant gastric irritability, 
blood in vomitus or stools, pain immediately after food which is 
relieved by vomiting, and pain on local pressure. Jacobi has given 
the following interpretation of the relation between pain and the 
ingestion of food: Pain half an hour or an hour after food points to 
duodenal ulcer, or peritonitic adhesions of the duodenum; pain three 
or four hours after a meal may be referred to the colon; pain most 
marked when the stomach is empty and relieved by food usually indi- 
cates a neurosis. 

Treatment. — The patient should be given easily digested food in 
small amounts at frequent intervals. Peptonized milk or skimmed 
milk and gruels, buttermilk, dextrinized gruels, light cereals and egg 
water may be tried. The acidity of the stomach may be lessened by 
the simpler alkalies, such as calcined magnesia, milk of magnesia, 
carbonate of lime and similar preparations. The stomach may be 
partially rested by rectal feeding. - If pain is severe, bismuth subcar- 
bonate and small doses of morphin or codein may be employed. In 
chronic cases, small doses of silver nitrate, gr. 1/20 to gr. 1/10, three 
hours after eating, may be tried for an interval of a week or so. In 
cases of perforation, surgical treatment is indicated. This, fortu- 
nately, is rare. 



214 DISEASES OF CHILDEEN. 



Chronic Gastritis. 



Definition. — A chronic disturbance of the gastric function, asso- 
ciated usually with a similar involvement of the intestinal tract. 

Etiology. — Improper feeding at irregular intervals is the main 
cause, especially when coupled with bad hygienic living. Rickets, 
tuberculosis, and chronic affections of the liver predispose to a chronic 
gastritis. Among the well-to-do or pampered children it results from 
the use of sweets, pastries, and rich dressings which the child is 
allowed to have. 

Symptomatology. — Frequent vomiting first attracts the attention 
of the parent. This after a time follows each meal. There are eructa- 
tions of gas and a feeling of discomfort after eating. The tongue is 
coated. The appetite is capricious. The outline of the stomach 
shows a well-marked dilatation. The abdomen remains quite per- 
sistently distended in spite of medication. The child is fretful and 
restless in sleep; the weight falling off gradually in aggravated cases. 
In infancy the picture of marasmus may be seen. Periods of pros- 
tration and collapse may precede a lingering death. Older children 
show no inclination to play, slowly grow more feeble and flabby; mucus 
is seen with greater regularity and in greater quantity in the vomitus. 

Diagnosis. — From a basilar meningitis the disease may be dis- 
tinguished by the absence of stupor or coma and lack of reflex changes. 
In doubtful cases the Von Pirquet reaction or a study of the spinal 
fluid could be resorted to for verification. Pyloric stenosis should be 
excluded by careful physical examination and the character of the 
vomiting. 

Course and Prognosis. — The disease may last for weeks and the 
child drag on a miserable existence until it succumbs to a terminal dis- 
ease, such as bronchopneumonia or marasmus. Infants rarely with- 
stand the disease, while if they survive they are apt to be weak and 
puny. In older children the prognosis is better and treatment of 
greater avail, although convalescence is prolonged sometimes through 
months. 

Treatment. — If all children were brought at stated intervals 
to their physician for examination and counsel, whether well or ill, 
chronic gastritis would be a much rarer disease. '^ Proper food prop- 
erly given" is the prophylactic treatment. The treatment is mainly 
dietetic. A careful history and study of the previous diet is the first 
requisite. Find the factor that is causing the disturbance; determine 
whether it is the butter fat, carbohydrates, or protein elements, for 



DISEASES OF THE DIGESTIVE TRACT. 215 

example, that is at fault. The periods of feeding, the quantity, the 
quality, and the digestive ability of the stomach itself must be weighed 
in the balance and corrective measures instituted as described in the 
chapter on Infant Feeding. The fact must -not be lost sight of that 
some children cannot digest cow's milk in any form. For the correc- 
tion of the A^omiting and to control the failing nutrition it is necessary 
to supply such food as will meet the lowest nutritional requirements, 
and in as readily a digestible form as possible. It is well to wash out 
the stomach before beginning the treatment. The legume flours, as 
pointed out by Edsall and Miller, are excellent substitutes for cow's 
milk if it disagrees, and they furnish sufficient protein to keep up nutri- 
tion. / Beef blood, yolk of egg, and gruels are to be tried, and if they 
agree, that is, cause no vomiting, may be alternated so that they will 
not pall on the appetite. If an increase in weight is obtained, weak- 
ened regular milk feedings may then be cautiously tried. / Occasionally 
the stomach-tube must be used in obstinate cases-. Rectal feeding is 
without much merit in these cases. Children two to three years old 
are often benefited by a change to the seashore. The appetite is 
thereby stimulated and the strict dietetic regime more willingly fol- 
lowed. A special diet list should be prepared by the physician for 
each case. From this should be excluded all sweets, gravies, and 
pastries. Milk, gruels, eggs, and the softer vegetables shoufd be the 
mainstay. Coupled with the dietetic management, the daily routine 
of the child should be outlined. A fresh-air life, plenty of sleep, plenty 
of water to drink, and agreeable baths are necessities. Cases seen 
late or doing badly require stimulation, and this is best given in the 
form of the tincture of nux vomica three minims well diluted one-half 
hour before meals. Constipation is relieved by milk of magnesia or 
cascara in children or with a suppository in infants. 

Dilatation of the Stomach. 

Etiology. — This condition results from causes which tend to 
weaken the muscular walls of the stomach. It is more commonly ob- 
served in infants suffering from constitutional diseases, such as rickets 
marasmus,_ syphilis, and tuberculosis. Among the rarer causes are 
pyloric hypertrophy or stricture. 

Symptomatology. — Those which resiTlt in the course of the consti- 
tutional diseases will be here described. Vomiting occurs usually 
some time after meals; food is not taken with avidity, and later in the 
disease may be abhorent. ' Constipation is a noticeable s^-mptom.- 
» The abdomen is usually tympanitic, tongue coaled, and in older chil- 
dren headaches may be complained of. • 



216 DISEASES OF CHILDREN. 

Physical Examination. — In emaciated subjects the greater cur- 
vature of the stomach may be seen on inspection. The abdomen is 
generally prominent, but percussion over the dilated viscus gives a 
highly resonant tympanitic note. If fluid is present a succussion note 
can be obtained by tapping with the ends of the fingers. If the diagno- 
sis is still indefinite, water or air may be introduced as an aid in deter- 
mining its size and capacity. 

Prognosis.^Unless due to a congenital stenosis, the prognosis is 
fairly good, but the course is slow and dependent upon the underlying 
disease. In itself the condition may retard the progress of a case of 
rachitis, for example, or even become the factor that may lead to a 
fatal termination. 

Treatment. — The motor inactivity necessitates in the beginning a 
course of gastric lavage coupled with dietary regulations as outlined 
under the article on Chronic Gastritis. Fresh air, massage, electricity, 
or vibration will be additional aids, no matter what the underlying dis- 
ease. The tincture of nux vomica in small doses will stimulate the 
appetite and assist the motor functions. If the disease is depen- 
dent upon a stricture, radical measures may be necessary to effect 
a cure. 

Stenosis of the Pylorus and Pyloric Spasm. 

{Congenital hypertrophy of the pylorus.) 

This is a condition in infancy in which there occurs an obstruction 
to the passage of food from tl^e stomach as a result of hypertrophy 
or spasm of the pylorus. 

Etiology. — There are no positive etiological factors known. 

Pathology. — The muscular, and occasionally the connective tissue 
at the pylorus, is hypertrophied. The stomach is dilated and thick 
tenacious mucus is found on the mucous membrane. 

Symptomatology. — The disease is usually not recognized when the 
first symptom appears. An apparently healthy infant at the breast 
may begin to vomit after nursing. This being repeated at frequent 
intervals, advice is sought. The usual corrective measures do not 
suffice and the vomiting is more persistent. Closer observation will 
show that the stools are extremely small, that the urine is scanty, and 
that the vomitus is projectile in type. The diagnosis now becomes 
more apparent. Physical examination may show a thickening about 
the pylorus, especially if anesthesia is used, but this is not always 
present. The cases of simple pyloric spasm do not give evidences of 
tumor formation; the vomiting is not quite so persistent, and the 



DISEASES OF THE DIGESTIVE 'TRACT. 



217 



emaciation not so rapid. I The stools are small and like dry putty, 
sometimes alternating with diarrhea. > Owing to the obstruction, 
little or no chyme enters the duodenum, and progressive emaciation 
results. •. The stomach is dilated, but the intestines are collapsed, 
a valuable sign in this disease.. A peristaltic wave may be observed 




Fig. 60. — (a) From a case of congenital hypertrophic pyloric stenosis: infant 
six weeks old — seen by one of us. (6) section of tumor in same case. 



passing from left to right upon slight mechanical stimulation. ( Ex- 
amination of the stomach contents shows a mixture of food and 
mucus, but without any bile. Hyperchlorhydria may be present. 
If measures for relief have not been successful the child dies of 
starvation. 

Diagnosis. — The characteristic vomiting without dietetic error, 
visible peristalsis, and a palpable tumor are of especial diagnostic 



218 DISEASES OF CHILDREN. 

importance, l If to these are added the sunken abdomen and pro- 
gressive emaciation, the diagnosis should be more certain.; 

Course and Prognosis. — In cases of true stenosis, due to hyper- 
trophy, the course is progressively downward and, unless there is 
successful intervention, ends fatally in ^ to ten weeks. (Some cases 
reported lived to twenty weeks and one five years.) f Cases have been 
cured by medical treatment alone, but appear to be those in which 
there was spasm only present and not a true stenosis. Heubner is 
inclined to give a hopeful prognosis with palliative treatment, i It is 
certain that the older the infant becomes before symptoms appear, 
the better its chances for recovery. « 

Treatment. — As soon as the diagnosis is made, stomach washing 
should be regularly done twice a day. The food, preferably 
breast milk, should be fed by gavage and always after the stomach 
washing. 

Mustard applications, one to six of flour, may be tried before 
feedings. If the vomiting persists so that no gain is made, surgical 
intervention should be resorted to as offering a hope of recovery. 
The surgeon will elect to do a gastroenterostomy or a pylorodiosis 
(Loreta's operation). As the number of failures reported is far 
behind the cures recorded, we will offer no statistics on this point. 

Cyclic Vomiting. 

{Recurrent Vomiting, Periodic Vomiting.) 

This symptom-complex occurs in older children and is character- 
ized by periodical attacks of vomiting and prostration, usually with- 
out fever and without indiscretions in diet. 

Etiology. — The condition is usually ascribed to some form of 
toxemia. Children from five to twelve years of age are more fre- 
quently affected. It is more apt to occur in the families of the well- 
to-do than in the poor. Metabolism is disturbed, as shown by the 
presence of the acetone and diacetic acids in the urine. Edsall 
believes that in the majority of cases faulty digestion is the underlying 
factor. 

Symptomatology. — In cases already under observation, a prodro- 
mal stage may sometimes be detected, but for the most part the attack 
comes on suddenly in children who are considered to be in good health. 
Occasionally constipation, lassitude, loss of appetite and a slight 
temperature precede the attack. The vomiting is persistent, recurs 
frequently and sometimes contains blood; nothing is retained. The 
child soon shows the effects of the strain, lying quite prostrated with 



DISEASES OF THE DIGESTIVE TRACT. 219 

sunken eyes, anxious expression, coated tongue, sweetish breath, and 
a high pulse. Thirst is a prominent symptom and cannot be reheved 
on account of the vomiting. The abdomen becomes scaphoid in 
shape, and sometimes is sensitive to the touch. Constipation is almost 
the rule. There may be periods in which vomiting ceases for a short 
time and some fluid or food can be retained. The attacks recur in 
varying periods — it may be weeks or months. The urine when 
examined is found deficient in amount and clouded, and usually gives a 
marked acetone reaction. Indican, diacetic acid, albumin, and casts are 
occasionally found. Recovery is rapid when the attack has ceased 
and food can be retained. 

Diagnosis. — This must be made after excluding meningitis, 
nephritis, and appendicitis. The sudden onset, acetone breath, 
absence of high temperature in a child without a history of dietary 
indiscretion^ would call attention to this symptom-complex. 

Prognosis. — As to hf e, the prognosis is distinctly favorable, although 
fatal cases have been reported. The attacks tend to recur unless the 
underlying cause be removed. 

Treatment. — Of the attack. Rest of body and stomach are 
essential; nothing should be given by mouth. To allay the thirst, 
colonic irrigations of normal salt solution, allowing four to six 
ounces to be retained, are effective. If the attacks persist beyond 
the second or third day, codein hypodermatically may be neces- 
sary, followed by nutrient enemata. Peptonized milk with whisky 
serves this purpose. Small doses of carbonated water may be tried 
when the vomiting begins to abate. Later, hot broths, dextrinized 
gruels, orange juice and semisolid food is offered until convalescence 
is established. 

In the Interval. — This should be influenced by the family history, 
the dietetic' faults, and an examination of the urine. The child should 
be under constant medical supervision. A suitable diet list should 
be prepared, and its effect on the urine noticed. The bowels should 
never be allowed to be constipated. A specific amount of water should 
be given daily. The daily life of the child must be apportioned, as in 
this way only may we hope to prevent recurrences. 

Stools. 

The stools of the breast-fed infant may be from one to five in 
number, and numerically we should not judge them as abnormal, pro- 
vided their color, consistency, and odor are within the normal limits. 
Their color should be a yellow or orange tint with homogeneous con- 



220 DISEASES OF CHILDREN. 

sistency produced by the unchanged biUrubin. Their reaction should 
be acid and the odor not disagreeable. The amount of residue found 
in the stools will be in direct proportion to the amount ingested or 
retained. The latter statement, however, does not hold true for the 
babies artificially fed. 

Stools of Artificially Fed Infants. — Cow's milk normally produces 
a stool lighter in color, bulkier, and numerically fewer. The feces 
amount to about 5 per cent, of the food ingested. In the hand-fed 
infant the protein elements are longer exposed in the intestinal canal 
to putrefaction. 

Examination of Stools. — If we examine a freshly passed stool from 
an infant fed on human milk, and with an improvised spatula spread 
out a central portion, we may find that there are yellow masses or 
flakes piesent; these are often mistaken for curds, but in reality are 
made up of fats; firm, hard curds are not found in mother's milk — only 
in cow's milk. Such a stool in an infant not steadily gaining would in- 
dicate a scanty milk supply, and if the stools were frequent, dark 
green and mucoid, with very little milk residue, the maternal font 
would surely be found to be at a low ebb. The indication would be 
wet-nursing or alternate feedings and regulation of the diet and life 
of the nurse. 

In the bottle-fed baby we are often confronted with the symptoms 
of constipation or diarrhea. Either of these conditions may arise 
from too much protein in the food. The constipated stool will 
be friable, like dry putty, while the loose stool due to this cause 
can be smoothed out and the masses will be readily soluble in 
ether, proving them to be fat and not curds, as they are so often 
designated. 

True curds are formed in the stomach by the action of lactic acid 
or an excess of hydrochloric acid and rennet on the paracasein. The}^ 
aria hard, smooth, yellowish on the outside and white within, with a 
cheesy odor when opened, and will not dissolve in ether. The remedy 
for too much protein is evident. Correct the formula, and if true curds 
are present, examine the character of the milk. The milk may have 
been sterilized or it needs to be mechanically diluted with gruels, or 
chemically modified, when the stools will assume the normal type. A 
loose, greasy, sour-smelling, acid movement, resembling scrambled 
eggs, will indicate excessive fat in the dietary. Examination of the 
breast milk or a study of the formula will show that the fats ingested 
have been persistently too high. Three per cent, of fat should never be 
exceeded by an infant to the third or fourth month, and more than 
four per cent, should never be prescribed. It should be recollected 



DISEASES OF THE DIGESTIVE TRACT. 221 

that a certain amount of fat is always present, but should not be visible 
in distinct masses. 

Mothers often erroneously speak of large quantities of mucus as 
present in the baby's stools. The doctor must remember that some 
mucus is normal; that it should, however, be found intimately mixed 
with the feces. Barley water produces a slimy stool often mistaken 
for mucus, and undigested food elements also cause this error. If 
mucus is seen in any quantity with the naked eye by a competent ob- 
server, it is pathological and means inflammation, usually located in 
the large intestine, of a subacute or chronic form. If the disease is in 
the small intestine, the mucus is mixed with the stool and it is usually 
found to be bile-stained. The hint for correction is embodied in the 
following fact — that the greater the amount of nonassimilable 
substances present, the greater the amount of mucus. The color of 
the stools when immediately passed should be considered. If the 
absorptive process has been delayed and putrefactive changes have 
taken place in the protein element, the bilirubin will be changed to 
biliverdin, but it is not known whether the reaction itself, or chromo- 
genic bacteria, produce the coloration. Nitric acid will prove whether 
or not we are dealing with bile salts by the familiar play of colors. 
The green color in conjunction with mucus, and fecal acid reaction, 
indicate true intestinal disease and call for radical change in the die- 
tary. Acid fermentation will require such temporary food as albumin 
water for its correction, while alkaline putrefaction will respond to the 
carbohydrate foods, as clextrinized gruels. The brownish movements 
often seen, if we exclude certain drugs and blood, are due to the inges- 
tion of undextrinized starches alone, or a preponderance of carbohy- 
drates in proprietary infant foods. 

A stool that presents a foamy, bubbling appearance and is acid 
in reaction will signify the presence of too much sugar in the mixture, 
as is often the case in canned condensed-milk feedings. 

We have not hinted at the bacterial examination of the stools^ as 
it has proven of no clinical value as yet. The reaction of the stool is a 
help and should be ascertained, and always taken from the middle of*' 
the fresh stool. If a blue color is obtained, we have alkaline protein 
putrefaction going on, and if the color of the litmus is unchanged, we 
have acid fermentation due to the breaking down of the fats and 
carbohydrates. (For further tests see page 52.) '' 

Again, the stools may be of considerable aid to us in certain 
pathological conditions, as illustrations of the intensity of the process 
in the summer diarrheas, and in such pathological states as intus- 
susception, in which we have frequent paroxysmal discharges with 



222 DISEASES OF CHILDREN. 

blood and mucus, but no feces. Rectal polypi should be strongly 
suspected where we have a normal stool, except for a fresh-blood 
coating; these hemorrhages being intermittent in character and not 
necessarily connected with a hard or scybalous mass. Fissures may 
be produced by hard fecal masses and have a blood coating, or in 
their passage produce bleeding from the rectum. Dark grumous blood 
mixed with the feces is indicative of hemorrhage, higher up in the 
bowel — probably from intestinal ulcerations. In gastric or acute 
duodenal ulcer there is vomiting of blood and mucus, but there is no 
fresh blood in the stools. 



Colic. 

{Enteralgia.) 

The term colic is used to designate the paroxysmal pains which 
occur in the abdomen. It is a symptom and not a disease, and usually 
denotes the presence of an abnormal amount of gas in the intestines, 
which stimulates undue peristaltic movements. 

Etiology. — It occurs most frequently in artificially fed, babies, as 
a result of digestive disturbances dependent upon the food ingested. 
This food may have been unwholesome, too great in amount, or one 
of its constituents may have been in excess. For example, the per- 
centage of proteins in a given mixture may be too high, or the sugar 
may cause fermentation if present in undue amounts (beyond 6 per 
cent.), or there may be starchy indigestion. Breast-fed infants may 
suffer from a poorly balanced milk or from overfeeding or too hasty 
nursing. 

Colic occurring in the course of other disease is dependent upon 
the resulting atonic condition of the intestinal walls. 

Symptomatology. — The attacks come on suddenly, the infant is 
restless and uneasy, and cries unceasingly. The abdomen is dis- 
tended and rigid and the thighs are drawn up over the abdomen. 
The extremities may be cold. If during the examination some flatus 
is expelled the screaming ceases and the evidences of relief are 
apparent. 

Treatment. — In the attack, heat should be applied to the 
abdomen, an enema of warm saline solution should be given and sips 
of hot water given by mouth. These measures will usually be effec- 
tive. If relief is not obtained, massage of the abdomen with warm 
olive oil, followed by a hot colonic irrigation containing two drams 
of the milk of asafetida to four ounces of water can be used. 



DISEASES OF THE DIGESTIVE TRACT. 223 

The following prescription may be of occasional service: 

I^. Chlorali hydrati gr. viii 

Sodii bicarbonatis gr. x 

Sodii bromidi o ss 

Aquae menthse pipertse oss 

Aquae q. s. ad Bij 

Misce et signa. — Give a teaspoonful in a little hot water every 
two or three hours. 

The further treatment resolves itself into efforts to discover the 
cause of the colic. The details of the preparation and administration 
of the infant's food may disclose a fault worthy of correction. The 
care of the mother or wet-nurse must not be forgotten when colic 
is present in the breast fed. 

Acute Gastroenteritis. 

{Summer Diarrhea. Summer Complaint, Infectious Diarrhea.) 

Etiology. — Artificially fed babies in the hot, humid summer 
months are especially prone to this infection, superinduced by the 
ingestion of unwholesome milk. Infants and children under two 
years are mainly attacked. The children in the tenement-house 
districts of our large cities show the greatest morbidity to infectious 
diarrhea. The bacillus dysenterise (Shiga-Flexner bacillus) can be 
isolated from many of the stools. The infection is usually from with- 
out, but autoinfection is possible. The lack of refrigeration, the 
feeding of food unfitted to the age, plus the devitalization by the 
summer heat, makes infection easy and common. Babies in crowded 
hospital wards may become infected by careless handling of the 
soiled diapers. 

Pathology. — No special characteristics are observed at necrops}^ 
A congested mucous membrane in the stomach and small intestine, 
with enlarged lymph glands, are commonly observed. Cloudy swelhng 
of the kidneys is quite constant. 

Symptomatology. — Mild Form. — The stools first attract attention. 
The}^ are curdy, loose and foul. The fever is moderate and the child 
fretful. The character of the stools soon changes to a greenish-yellow, 
and they become more numerous, five to six a day, and the fever 
rises to 102° or 103° F. If prompt measures, as indicated below, are 
taken, recovery is rapid and quite certain. 

Severe Form. — Vomiting with loose, frequent spinach-green 
stools and high fever may be seen at the outset or result from neglect 
of the milder types. Vomiting follows the ingestion of nearly all the 
food offered. The fever and inability to take food produce weakness 
and extremely rapid emaciation, and later a comatose condition with 



224 DISEASES OF CHILDREN. 

marked prostration. The fontanel is sunken and the pulse is weak. 
The stools may be streaked with blood and contain mucus in consider- 
able quantity. The fever frequently rises to 104° or 105°, F. and 
death may be preceded by coma or convulsions. 

Toxic Form. — From the onset the symptoms are usually severe. 
High fever and intense prostration are added to the vomiting and 
frequent stools. The color of the stools is constantly green, the odor 
extremely foul, and blood-streaked mucus appears early. Cerebral 
symptoms soon supervene, delirium and coma usher in the end, which 
may come on in a day or two, or even within twenty-four hours. In 
this form the Shiga bacillus can usually be demonstrated. 

Course and Prognosis. — This has been indicated under the 
separate divisions, depending upon the severity of the infection. If 
seen early, the mild and severer forms are amenable to treatment, 
while the toxic type usually baffles even the most heroic measures. 
The ability to command good nursing and change of locality naturally 
influence the prognosis. 

Treatment. Prophylactic. — Breast-feeding whenever possible, 
especially in the summer months, is desirable. Cleanliness and care 
in every detail of the child's diet and clothing are necessary. The 
use of pasteurized or constantly refrigerated clean milk is indicated. 
Proper disinfection of stools and the nurse's hands must be insisted on. 
Regulation of the diet, according to the heat and the condition of the 
infant, will help in prevention. 

General Management. — Place the patient in the coolest, cleanest 
and largest room possible. A cotton slip and diapers only are to be worn. 
Secure a competent nurse if possible to intelligently follow orders. Re- 
duce the fever by frequent cool sponging or tepid baths. If the tempera- 
ture is above 104° F. and the pulse permits, use an ice-bag to the head. 
An initial purge with castor oil or calomel is indicated (see p. 226). 

Dietetic. — Stop milk in all forms for at least twenty-four hours, 
placing the child on a starvation diet of boiled water alone or on barley 
water, made with one ounce of flour to the quart. If at the end of a 
day the frequent stools persist, continue the substitute feeding until 
a change for the better is noticed. 

If barley gruel is not palatable or tolerated, one may try rice water 
or albumin water. (See section on Dietetics.) In the case of nurslings 
resume the feeding at longer intervals preceded by a dram or two of 
boiled water. In artificially fed babies, resumption to cow's milk 
feedings must be made only when the stools resume the normal type. 
Whey or buttermilk feedings are serviceable substitutes. Begin with 
a modification lower than the original prescriptions. 



DISEASES OF THE DIGESTIVE TRACT. 225 

The diarrheal diseases of infancy and childhood do not permit as 
yet of any definite classification, for the etiological factors may be 
the same in a number of the allied affections, and the various patho- 
logical changes found are often those of degree or situation only. It is 
to be hoped that in the near future these grouped diseases may be 
more accurately separated and defined. 

Acute Enterocolitis. 

Definition. — This is an inflammation of the mucous membrane of 
the small and large intestine associated with ulcerations and charac- 
terized by tenesmus and blood-stained stools. 

Etiology. — Children in the summer months, especially those who 
have had previous attacks of gastroenteritis, or who suffer from 
chronic indigestion, are especially liable to attack. The children of the 
poor in the large cities because of improper food and uncleanliness are 
most frequently the victims of the disease. Such constitutional dis- 
eases as rickets, tuberculosis, and syphilis are predisposing elements. 
The Shiga bacillus is found in a great many of the cases. 

Pathology. — In the colon and about the ileocecal valve the charac- 
teristic lesions are commonly observed. In some of the lighter forms 
of the disease we find only evidences of congestion and inflammation 
with a roughened or somewhat denuded epithelium. 

The lymphatic structures are hypertrophied or show loss of tissue. 
If the affection has been of a severer grade, the follicles are degenerated, 
producing a slight ulceration and consequent uneven feel to the gut. 
These changes are commonly seen in the colon and rarely in the 
ileum or rectum. In the usual type seen after a severe illness quite 
deep ulceration may exist, so as to produce a shaven beard appearance. 
The ulcers may later extend down to the muscular layer, and a large 
area of ulceration may be found by the coalition of a number of smaller 
ulcers. Another type occasionally seen presents a fibrinous deposit 
over isolated areas of the colon. Quite generally there is a swelling 
of the retroperitoneal and mesenteric glands. Bronchopneumonia 
patches are often found at necropsy. 

Symptomatology. — In a child whose vitality has already been im- 
paired by previous disease the attention may be directed to the con- 
dition of the stools, which are passed with much straining. These stools 
may contain blood-streaked mucus with undigested food masses. 
Fever is quite constant and varied in degree, in the beginning 102° to 
105° F. and a correspondingly rapid pulse rate. In the severer cases 
there is rapid prostration and vomiting. The stools are passed with 






226 DISEASES OF CHILDREN. 

abdominal pain, and tenesmus may be marked. There is restlessness 
and often delirium. Thirst is intense. The eyes are sunken and 
expressionless. The lips and tongue are dry and coated. The stools 
are now frequent — from ten to twenty a day — small, and contain 
almost no feces. Death will occur from exhaustion or a pneumonic 
complication if the symptoms do not show signs of abatement. Im- 
provement is shown by a decrease in the number of stools, a lowered 
temperature with absence of vomiting and tenesmus. The lost vitality 
is regained very slowly. For days or weeks there is a low-grade tem- 
perature, and temporarily the tenesmus or green stools may appear. 

The appetite is capricious for a long time. The abdominal tone 
which is lost during the height of the disease will now slowly return to 
the normal, and the child will gain in weight. 

Diagnosis. — The diagnosis is made from the presence of mucus and 
blood in diarrheal stools passed with straining over a period of several 
days or weeks in a child of deficient vitality. 

Intussusception is differentiated by the absence of fever, the 
acute onset, the pain, the presence only of mucus and blood, but no 
feces, and a tumor palpable through the abdomen or rectum. 

Course and Prognosis. — Severe types end fatally after a few days, 
or a week at most, of high fever and prostration. The mortality rate 
is from 30 to 40 per cent. The subacute types remain ill for a month 
or six weeks with periods of remission and relapses and a slow painful 
convalescence. The prognosis is more favorable in this class, especi- 
ally if they are removed to suitable surroundings, and have proper nurs- 
ing and attendance. Infants withstand the disease badly. 

Treatment. — This does not differ from that given on page 223, 
under Diarrheal Diseases. It should be recalled that these infections 
may be communicated to others in a family or ward. An initial 
cleansing of the bowel with castor oil or calomel is imperative, followed 
by starvation for twelve to twenty-four hours. Egg albumin, bar- 
ley water, or beef broth may be given (see p. 175). Equal parts of 
beef broth or barley gruel (1 oz. to the pint) are sometimes more 
acceptable. 

The tenesmus is relieved by the control of the diet and by the use 
of codein gr. ^ to J, according to the age, or Dover's powder, gr. |- to 2 
grains every two or three hours, until the painful symptoms abate. 
Suppositories containing cocain gr. J and aristol gr. -J- are soothing in 
older children. Bismuth subnitrate gr. 5-10 or bismuth subgallate gr. 
2, with powdered ipecac gr. 1, may be given advantageously every 
two or three hours for the control of the mucus and blood in the stools. 

Whey is permitted when the stools show improvement, and after 



PLATE VI. 




Measles, showing typical eruption. 



DISEASES OF THE DIGESTIVE TRACT. 227 

the acute symptoms have subsided sterihzed milk is allowed in small 
amounts well diluted with barley or wheat-flour gruel. Later pasteur- 
ized milk is permitted with jellied gruels and broths. The prostration 
may require hj^podermatic medication in the form of atropin gr. ^^-^ 
with strychnin sulph. gr. yto-- -^s a daily routine, one saline irrigation 
at 100° F. serves a double purpose, as a cleansing solution and for 
absorption of part of the water. Strychnin sulphate gr. -g-^-Q may be 
given as a tonic three times a day, and astringent enemas for the 
control of blood and mucus. Silver nitrate (tto o") or a starch paste 
in less severe cases may serve the latter purpose. They should not 
be given more than once daily, and discontinued if the effect is not 
satisfactory^ Too frequent irrigations often cause irritation and ag- 
gravation of the symptoms. Removal to the seaside or cool mountain 
air is a great help in the management, particularly in the convalescent 
stage. 

Chronic Gastrointestinal Indigestion. 

This is a condition congenital or acquired, resulting from deficient 
motor and secretory powers in the alimentary tract, or as a result 
of improper food. 

Etiology. — Improper feeding, especially in poor children in the 
cities where the surroundings are unhygienic, is the principal cause of 
this affection. When the food is radically wrong, or unwholesome, an 
acute condition develops which makes the parent seek medical treat- 
ment; on the other hand, the chronic condition due to incapacity to 
digest certain ingredients of the food is often overlooked or ascribed 
to anemia, parasites, etc. An excess of the fats, carbohydrates, and 
sugars or of the proteins may overtax the intestinal digestion, thereby 
using up energy which should have produced development and growth. 

In older children badly prepared foods or indulgence in rich foods, 
pastries, and condiments lead to this condition. 

Pathology. — There are no definite organic changes found in this 
disease. If of long standing, the lymph foUicles in the region of the 
ileocecal valve may be hypertrophied or a chronic colitis may be 
found. 

Symptomatology. — As indicated above, the symptoms are not 
appreciable at first, unless the disease directly follows an acute gas- 
tritis or enterocolitis. After some time failure to gain weight is 
noticed; the child sleeps badly, has frequent attacks of cohc, and cannot 
easily be comforted; the stools become diarrheal for several days then 
resume a more normal appearance, only to relapse into a condition of 



228 DISEASES OF CHILDREN. 

diarrhea or even constipation. Closer examination of the stools 
shows that they consist of masses of undigested food, intermingled 
with a small quantity of mucus, while streaks or splashes of green color 
are not infrequent. 

The musculature becomes soft and flabby. If the child has pre- 
viously sat up or walked, it may now be unable to do so. The abdom- 
inal wall offers little or no resistance on palpation and the normal 
peristalsis is sluggish. The temperature is rarely elevated except late 
in the disease; on the other hand, a subnormal temperature is not 
uncommon. Intertrigo in the napkin region is exceedingly common. 
If corrective measures have not been instituted by this time a marantic 
condition supervenes which may lead to a fatal issue. 

In older children the symptoms are not as marked, but the sta- 
tionary weight or loss of weight, anemia, and listlessness should recall 
the possibility of this condition. The appetite is capricious, and as a 
consequence the children are indulged to a vicious degree by their 
parents. Attacks of constipation alternate with diarrhea, the urine 
is somewhat decreased in amount, it may be cloudy, and contains 
an excess of indican (see Plate I). The children become irritable 
and moody, having seemingly lost their former characteristics. They 
become cold easily, develop headaches, and are easily nauseated. 
The abdomen becomes prominent from gas distention, the stomach 
itself, if mapped out, shows enlargement, but there is no pain or 
tenderness on abdominal palpation. 

Treatment. — Good hygiene and proper dietetic treatment are 
absolutely necessary to effect a cure. In the case of the poor, removal 
to a properly conducted hospital, preferably one near the seashore, 
will often work wonders. 

The diet must be so adapted that it will correct the former faults, 
but still take into consideration the deficiency of digestive secretion 
and maldevelopment of the alimentary tract. An analysis of the 
breast milk or of the last formula given to an infant, studied in con- 
nection with its stools, will usually show which ingredient is at fault. 
A wet nurse will sometimes quickly produce an amelioration of the 
symptoms. Detailed instructions as to the room, air, bathing, and 
exercise must be given if the patient is to remain at home. The roof 
or piazza can be effectively utilized, and the greater part of the day 
should be spent out of doors. Before any dietary changes are made 
it is well to wash out the stomach, and thoroughly irrigate the bowels 
with saline solution. In some instances the bowel irrigations may 
have to be repeated once or twice. An initial dose of castor oil, one 
to two drams and a minim or two of the tincture of nux vomica, 



DISEASES OF THE DIGESTIVE TRACT. 229 

three times a day, will usually constitute all the drug treatment that is 
necessary. 

If the infant is artificially fed, the milk can for a time be so 
modified as to prevent the curdhng action of rennet in the stomach 
by the use of peptonization or the alkalies or the addition of sodium 
citrate. A formula weaker than the requirements of a normal child of 
a corresponding age must be temporarily given. Rapid gain in weight 
must not be expected. Convalescence is slow and protracted. 

The management in the case of older children is mainly dietetic. 
From time to time a diet list of certain permissible articles of food 
should be given beginning with such as are easily digested and assimi- 
lated and gradually increasing the number and variety as the improve- 
ment warrants (see diet list, p. 197). 

Aerotherapy, stimulating baths, and massage are necessary 
adjuncts to the dietetic treatment. Without constant supervision 
and attention to the daily routine, meager improvement will be 
experienced. 

Congenital Dilatation of the Colon. 

{Hirschsprung's Disease.) 

This is a rare condition which consists of an increase in the length 
and circumference of the descending colon and the sigmoid flexure. 
In some cases there is an added hypertrophy of the muscle fibers. As 
a result of this condition the abdomen is greatly distended from 
meteorism, feces are more or less retained, the constipation is ex- 
tremely obstinate, and when the fecal masses are passed, either natur- 
ally or by artificial means, they are extremely foul, putrescent, and 
may be covered with mucus and some blood. 

Treatment. — Daily high irrigations must be used to produce 
bowel evacuation. Massage and douching of the abdomen with cold 
water should be persisted in for a long time. Internally the daily 
administration of a laxative and drop doses of the tincture of nux 
vomica before meals are advisable. 

Cholera Infantum. 

Cholera infantum is a very acute disease characterized by rapid 
prostration, vomiting, and a profuse serous diarrhea. 

Etiology. — It occurs almost entirely in the hot months of the year, 
among the poorer classes who live on inferior milk, and very rarely 
attacks breast-fed infants. It is the result of a toxic poisoning from 
an organism or group of organisms still undetermined. 



230 DISEASES OF CHILDREN. 

Symptomatology. — The symptoms are out of all proportion to the 
anatomical lesions which are found at necropsy. A child apparently 
quite well or only ill from a digestive disturbance suddenly begins 
to vomit and has a rise of temperature. A profuse diarrhea follows, 
possessing the characteristics of decomposition with very foul-smelling 
stools. The stomach and intestinal contents are at first expelled in 
this manner. The vomiting then consists of a watery fluid with flakes 
of mucus. The stools also now lose their fecal character, and are 
watery, greenish-gray in color, with a peculiar old musty odor which 
is quite characteristic. These discharges at first copious and explosive 
become smaller in amount but very frequent; they consist of serum and 
mucus, and may be as many as twenty or thirty a day. In some cases 
there is an almost constant oozing from the anal ring. The vomiting 
and diarrhea with the high temperature causes a quick collapse and an 
emaciation which is extremely rapid, due to the character of the dis- 
charge which is largely blood serum. The extremities are cold, the 
pulse feeble, the respirations shallow and sighing, and the infant lies 
in a semicoma. Thirst is extreme, and water is eagerly taken. Men- 
ingitic symptoms supervene, with dehrium, twitching, purposeless 
movements or convulsions. Unless the progress of the disease is 
arrested, the temperature rises to 105° or 107° F., with coma and 
death resulting from cardiac exhaustion at the end of the second or 
third day. If the treatment has been successful, the convalescence 
is extremely slow and demands incessant care. 

Course and Prognosis. — This should always be given as extremely 
bad. If prostration comes on rapidly, with high temperature and 
nervous symptoms, the course is often not longer than twenty-four 
hours. 

Treatment. — This must be energetic and heroic if any good is to 
be accomplished. Gastric lavage with warm saline solution should 
be made if the patient is seen early. If prostration is apparent, stimu- 
lation is the first indication, and is here best obtained by the use of hypo- 
dermoclysis which supplies the tissues with fluid and likewise stimu- 
lates. Inject eight to ten ounces into the subcutaneous tissue of the 
abdomen — using for this purpose sterile normal saline solution (6 grs. 
to the liter) and repeat this every four to six hours. Enemas of nor- 
mal salt solution ma}^ also be employed. For a very rapid effect a 
hypodermatic injection of atropin gr. -q^-^is efficacious, acting also as a 
check to the serous waste. This may be repeated every three hours 
if necessary. Camphor in sterile olive oil (one grain of camphor to 
every ten minims of oil) may be injected in the intervals, if the cardiac 
action is feeble. Immersion in warm baths at blood heat, or at 110° F. 



DISEASES OF THE DIGESTIVE TRACT. 231 

if the temperature should suddenly drop, is efficacious. They should 
be continued for a half-hour, and repeated at three-hour intervals; 
gentle friction and the addition of mustard, one tablespoonful to the 
bath, will assist in keeping the extremities warm. No food is permitted 
and no medicines should be administered by mouth until the danger 
of death from collapse is past. Should the child rally, cautious feed- 
ings and medication as outlined under the article on Summer Diarrhea, 
is to be followed under the supervision of a competent nurse. As 
soon as possible thereafter a change to the seaside should be made. 

Constipation. 

This should be regarded as a symptom and not a disease, and 
accordingly the underlying cause should be sought for and corrected. 

Etiology. Rare Causes. — The condition may be caused by con- 
genital anatomical abnormalities, by new growths, or by the dispro- 
portionate length of the sigmoid flexure. Adhesive peritonitis (espe- 
cially the tuberculous variety) also causes constipation. 

The commoner causes are mainly dietetic. Artificially fed infants 
are the most frequent sufferers because of badly balanced food mix- 
tures (see Artificial Feeding, p. 172), either too large or too small an 
amount of one ingredient of the milk, or the boiling of the milk itself 
acting as causes. Breast-fed infants are constipated from deficiency 
in the fat or total quantit}^ of solids present in the mother's milk. 
In older children a badly arranged dietary, especially a deficiency in 
the carbohydrates and fruit juices, will cause this symptom. Next to 
the diet, the lack of training of the child is an important cause in pro- 
ducing constipation. Children who suffer from constitutional diseases, 
such as rickets and infantile atrophy, may be constipated because of 
the lack of expulsive power and deficient peristaltic action. 

Other causes are deficiency of the intestinal and biliary secretions, 
nervous inhibition of the normal peristalsis in such diseases as menin- 
gitis, and intestinal parasites. The fear of causing pain w^hen at 
stool, as from fissures of the anus, may lead to constipation. 

Symptomatology. In Infancy. — Colicky pains and flatulence 
precede the passage of the fecal mass, which is hard and dry or putty- 
like. Absorption of the toxins may cause rise of temperature or 
possibly convulsions. These infants are inclined to be fretful with ca- 
pricious appetites and are poor sleepers. They are likewise inclined to 
eczema. Rectal examination will reveal the fecal masses. 

In Older Children. — The tongue is coated, the breath is foul, and 
there is lassitude and depression with headache. There may be a 



232 



DISEASES OF CHILDREN. 



slight rise of temperature, and the complexion becomes sallow or pasty. 
The appetite is lost. Sleep is disturbed. The stools are passed with 
an effort, may be mucus-coated and exceptionally large and ball-like. 
The child may go for several days without a movement. Digital 
examination will clear up any doubtful case. 

Treatment. — With persistent and patient effort all cases can be 
cured. The food taken by the child must be studied and the error 
which is usually dietetic set right. Medicines should have a minor 
place; the main reliance should be on diet, correct habits, and massage. 
Deficiency in the total amount or irregularity of any of the food 
components must be properly balanced. If the fats are deficient 
in the mother attempt should be made to improve the milk by dietetic 
and hygienic measures, and by regulating the amount of sleep and 
exercise. If this fails, alternate feedings or supplementary feedings 
of modified milk may be given. Nursing mothers should be placed 
on a diet list which would include plenty of clean raw milk, corn- 
meal gruel, and water between meals. Feeble infants in whom the 
efforts to expel the mass are unsuccessful, as is evi- 
denced by the finger in the rectum, are helped by 
gentle massage of the abdomen, the introduction of a 
gluten suppository or the nipple of a rectal syringe. 
Artificially fed babies are most often constipated be- 
cause they are usually on a modified food incorrectly 
ordered. See to it that there is a sufficiency of fat 
and protein in the mixture and that the curd is 
mechanically broken up by the addition of a gruel. 
Oatmeal gruel may be tried in infants suffering from 
constipation. Water between the feedings must be 
offered freely. A tablespoonful or two of orange or 
pineapple j uice is decidedly beneficial in infants after 
the first six months of life. Beef juice or chicken 
broth are laxative and may be judiciously employed. 
If the mixture has been made up with a proprietary 
infant food, this should be chang.ed. If the constipa- 
tion has been neglected for some time it may be necessary to use soap 
enemata, four to eight ounces at a time. Glycerin suppositories at 
first may be tried in conjunction with a proper diet and hygienic 
measures, and then gradually use milder procedures as improvement 
takes place. By simpler procedures is meant the injection of a few 
drams of olive oil or an ounce of warm water with a baby rectal 
syringe. 

The ehxir of cascara sagrada (N. F.) ten to thirty drops maybe 




FiG.61.— Rec- 
tal syringe for 
infants. 



DISEASES OF THE DIGESTIVE TRACT. 233 

prescribed, or malt and cascara given in the minimum dosage possible 
to produce a satisfactory movement (one-half to one teaspoonful). 
As soon as the supplementary measures can be depended upon, the 
medicines should be abandoned altogether. 

A regular stooling habit can be cultivated almost from infancy 
by placing the baby on a small commode at regular intervals and is 
a prophylactic measure of importance in child life. 

The constipation of older children may be corrected by the addi- 
tion of cream and butter to the food, or in other instances, a greater 
amount of vegetables and fruit must be ordered. Taking a glass 
of water on arising, followed by a cold sponging and abdominal 
massage will cure many cases if regularly carried out, besides im- 
proving the general body tone and blood-supply. Calomel, castor 
oil or the salts should not be given for this condition. They are 
cathartic in action and tend to produce constipation. 

Amebic Dysentery. 

Etiology. — Sporadic cases of amebic dysentery in children have 
come under our observation with greater frequency in the past few 
years. The diarrhea is characterized by profuse, watery stools ad- 
mixed with blood from which the ameba coli can be isolated. It 
probably occurs much more frequently than is recognized in our 
Southern States, and because of our colonial possessions it is more 
apt to gain an entrance into this country. The exact sources of infec- 
tion are not known but in all probability the intestinal tract is infected 
by contaminated drinking water or the ingestion of raw vegetables or 
fruits. 

The ameba is a unicellular bit of motile protoplasm having a 
clear outer zone and an inner granular area with a nucleus and usually 
some vacuoles are present. 

Pathology. — The lesions consist of ulcerations in the large intes- 
tines or the lower part of the ileum. Necrosis of the mucous membrane 
over these ulcers soon takes place leaving a dirty edematous, sub- 
mucous layer exposed. The ulcers are generally undermined with 
rounded infiltrated edges. In aggravated cases the muscular or even 
the serous coat may be exposed and the ulcers are then found extend- 
ing through the hepatic flexure into the rectum. 

Symptomatology. — An irregular diarrhea in a child which does not 
abate after the usual course of treatment should excite our suspicions 
and invite careful examinations of the stools for the presence of the 
ameba. This is especially true if sudden exacerbations occur after a 



234 DISEASES OF CHILDREN. 

period of apparent quiescence. The stools are usually very numerous, 
watery and contain mucus and blood. The blood varies in quantity 
and is out of proportion to the amount of mucus. During the ex- 
acerbations in which the patient will have abdominal pain and tenes- 
mus, the ameba are more likely to be found in the fresh stool. The 
course of the disease is rather protracted and convalescence is slow, 
usually complicated by a secondary anemia. We have never ob- 
served complicating abscesses of the liver or lungs in any of our cases, 
although these form most dangerous sequellse in tropical countries. 
The ameba are persistently found in the stools even after convalescence 
is well established and the stools are no longer dysenteric in character. 

Treatment. — The patient should be kept in bed at rest until the 
stools assume a formed character. This is necessary to prevent ex- 
acerbations and complications. The diet should consist of warm gruels 
or paps made from such articles as arrowroot, cornstarch or farina. 
It is best to withhold milk until the active symptoms have subsided. 
Eggs and thickened broths may be cautiously added, and finally whey 
and milk. 

The abdominal pain is relieved by hot turpentine stoops, and the 
tenesmus with thin starch enemata. Warm colonic irrigations of qui- 
nine in solution 1 to 1000 are destructive to the ameba. The syrup of 
the iodide of iron is indicated in convalescence as it counteracts the 
anemia. Change of climate should be ordered if possible and the 
attendants instructed to carry out typhoid precautions until the stools 
are entirely free of the infecting agent. 



PLATE III 




Ova of the cestodes of early life. Tenia solium (Pork tape-worm), p-p'; Tenia 
saginata (Beef tape-worm), q-q'; Bothriocephalus latus (Fish tape-worm), k-k'; 
Uncinaria americana (Hook-worm), x-x'-x"-x"'; Ascaris lumbricoides (Round- 
worm), y-y"; Oxyuris vermicularis (Thread-worm), d-d'-d"-d"'. 



CHAPTER XX. 

THE ANIMAL PARASITES. 

These may be conveniently divided into several groups and sub- 
groups (see table below). Only those that are found with some 
frequency in childhood will be described and pictured. 

Parasitic Protozoa. 

Animal Parasites Found in Childhood: 

Nematodes. — Oxyuris vermicularis (thread worm). Ascaris lum- 
bricoides (round worm). Trichina spiralis. Ankylostoma americana 
(hook worm). 

Cestodes. — Tenia saginata. Tenia -solium (pork tape-worm). 
Bothriocephalus latus. 

Although infection is more frequent with intestinal parasites 
among children than in adults, the cases are mainly found in the off- 
spring of foreigners in this country. 

These parasites are taken to be the cause of many of the ailments 
of children by parents frequenting the dispensaries and many of them 
have been given the therapeutic test without any clinical evidence of 
the parasites being present. When they are present in any quantities 
they may do harm, especially in sickly children, by impoverishing 
the albumin content, by acting as foreign bodies in unusual sites, 
and by poisoning their host through their metabolic products. The 
evil effect of intestinal parasites is often exaggerated in the mother's 
mind. 

Oxyuris Vermicularis. 

{Thread Worms.) 

These are small white filament-like worms usually found in the 
rectum. The female is larger than the male, and usually is found 
in the cecum, until impregnated, when it descends to the rectum. 

The eggs are oval, asymmetrical, about 0.05 mm. in size 
Their interior is filled with a granular yolk, containing a clear 
nucleus. The oxyuris differs from some of the other parasites 
in that it does not require an intermediary host. The worms and 
the eggs pass out of the rectum alone or with the feces, and may 

235 



236 



DISEASES OF CHILDREN. 



directly inoculate a human body. The child may reinfect itself by 
handling toys, or food, and may infect its playmates. 

Symptomatology. — The worms by their presence may produce 
irritation of the anus, or if present in sufficient numbers, even a colitis 
or proctitis may result. The children sleep poorly and scratch about 

the anus. They lose their appetites, be- 
come irritable, and even anemic. In girls, 
particularly, the parasites may invade the 
genitals, and result in masturbation or 
incontinence of urine. Sometimes no 
symptoms are to be noted. 

Diagnosis. — An enema of cold water 
will disclose any parasites present if they 
are not found in the stools or at the anus. 
The eggs are found with difficulty in the 
stools; more often they are found under 
the finger-nails of the infected child. 

Treatment. Prophylactic. — By atten- 
tion to the person of the patient, self-in- 
oculation can and must be prevented. 
Baths, clean finger-nails, restrictive ap- 
paratus for the hands or heavy canvas 
drawers to prevent scratching are some- 
times necessary. Examine other suscep- 
tible members of the family to prevent 
reinfection. 

Internal. — A grain of calomel or a tea- 
spoonful of Rochelle salts in water is given 
to bring down the females from the cecum. 
Locally. — Daily enemata of saline 
solution may be given followed three 
times a week by injections of the infusion 
of quassia, this to be retained for a time 
if possible. Further, a 2 per cent, yellow 
oxid of mercury ointment is apphed about and into the rectum at night. 
This treatment should be persisted in until the bowel is thoroughly 
rid of the worms, and renewed if any are seen at a later date. 

Ascaris Lumbricoides. 

{Round Worm.) 
This parasite is round with a smooth body from four to six inches 
long and pointed at each end. The mouth has three suckers and teeth. 




Fig. 62. — Oxyuris vermicu- 
laris. a, Sexually mature 
female; h, female with eggs; 
c, male. {After Heller.) 



THE ANI]\L\L PARASITES. 



237 



The female is very prolific, producing 
millions of eggs. These are rounded 
or oval in shape (see Fig. 63). It has 
been proven by experimentation that 
intermediary host is necessary. 



no 



Although they normally inhabit the 
small intestine, they move from place 
to place. They have been frequently 
vomited from the stomach and have 
been found in the gall-bladder and 
appendix in children. Through its 
ova it gains entrance to the human 
intestinal canal. 

Symptomatology. — The parents 
themselves often make the diagnosis 
of round worms when they have seen 
them passed. When questioned the 
majority of the patients do not give 
any symptoms directly referable to 
the w^orms, and many have had no 
symptoms whatever. The symptoms 
usually present are loss of appetite, 
nausea, or diarrhea, occasionally there 
are pains referable to the abdomen, 
which are soon forgotten, only to 
reappear again. Pruritus ani, pavor 
nocturnus, choreiform movements, 
and convulsions have been observed. 
A rather constant eosinophilia is pres- 
ent in patients with round worms, and 
this should be a stimulus to examine 
the feces for ova. By their local 
action or migration the}^ may produce 
obstruction of the intestine or even a 
fatal issue, as in laryngeal obstruction. 

Diagnosis. — The microscopic ex- 
amination for the ova is readily made 
and should not be omitted in ques- 
tionable cases having an eosinophilia. 

Treatment. Prophylactic. — 
Cleanliness of body, a pure water- 
supply, and avoidance of unboiled 




Fig, 63. — Ascaris lumbri- 
coides. A, A female; B, a male, 
natural size; h, cephalic end, en- 
larged, showing lips. {After 
Peris.) 






238 



DISEASES OF CHILDREN. 



vegetables for children decrease the possibility of infection. Care in the 
handling of the stools of children will also prevent infection of others. 
Internal. — Calomel and santonin is a dependable combination 
for this parasite. A half-grain of each drug with sugar of milk is usu- 
ally sufficient. Never give more than a grain of santonin, as poisoning 
may be produced. It is best given with some food 'and in divided 
doses. The stools should be examined for ova each week for three 
weeks, as until then there is no positive certainty of their absence. 

Cestodes, or Tape -worms. 

General Characteristics. — The tape-worms commonly met with in 
this country in children are the Tenia mediocanellata (or saginata) or 
beef tape-worm, and the Tenia solium or the pork tape-worm. They 
are flat, ribbon-like, jointed parasites, yellowish in color, and vary in 




Fig, 64. — Head of Tenia sagi- 
nata, much magnified. 




Fig. 65.— Head of Tenia 
solium, showing scolex, 
suckers, hooks, and neck. 



length from ten to twenty feet, the segments growing smaller until the 
head is reached. It is only in the intestinal tract of man that the fully 
developed parasite is found. The ova are taken into the ahmentary 
tract of an animal and their covering is dissolved and they then pass 
through into the muscles of the animal and become encj^sted there. 
Such meat is commonly spoken of as being ''measly." This infected 
meat when eaten by man allows the larvae to develop into the tape- 
worm. Although occurring rarely, man may himself act as the inter- 
mediary host and cysticerci develop in his organs. 



THE ANI^IAL PARASITES. 



239 



Tenia Mediocanellata or Saginata {The Beef Tape-worm), 

These worms may be distinguished by the appearance of their 
heads under the magnifying glass. The head of the beef worm is 
cuboid, sHghtly darker than the rest of the body and it has no hooks 
as the pork worm has; instead four suckers 
are seen on the head. Its eggs are smaller 
than that of the Tenia solium, and contain 
hooklets. 

^ Jii 

Tenia Solium (The Pork Tape-worm or 
the Armed Tape-worm). 

The head of this parasite which is about 
the size of a pin-head, has besides the four 
suckers found on the beef worm, a set of 
hooklets. They often reach nine feet in 
length. The eggs are round and contain 
the embryo with its hooklets. 

Symptomatology. — In the great major- 
ity of cases there are no pathognomonic 
symptoms referable to the teniae. Often it 
is only when the segments are passed that 
their presence is indicated. Older children 
may complain of grumbhng, griping pains, 
and have symptoms of indigestion. They 
become anemic, have headaches, and com- 
plain of dizziness. Sometimes a capricious 
or voracious appetite may excite suspicion, 
if coupled with a history of eating raw beef 
or pork. 

Treatment. Prophylactic. — Proper 
meat inspection at the abattoir. A dis- 
semination of the harm that may be caused 
by eating of raw or badly cooked meats 
and destruction by fire of all segments 
passed would materially reduce the number 
of these cases. The children of foreigners 
are especially to be warned. 

Internal. — The parasites can be removed if a systematic cure is 
outlined and rigidly followed, as the head is firmly attached and must 
be dislodged to effect a cure. First day: a dose of castor oil, at least 
a half ounce, is given, followed by fasting for the remainder of the day. 




Fig. 66. — Portions of a Tenia 
saginata. (After Leuckart, 
natural size.) 



240 



DISEASES OF CHILDREN. 



Second day: following a cup of clear consomme or weak tea, give 
the following prescription for a five year old child, while the child is 
kept in bed. 



Oleoresinse aspidii 5| 

Mucilaginis acacise , 5ij 

Spiriti chloroformi ttlx 

Aquae cinnamomi q.s. ad. 5 j 

Misce et Sig. — One-half the quantity at a dose. 



The remainder is given after a few hours, if the child should vomit 
the first dose; they rarely reject the second, if kept prone in bed. 

Several hours after the vermifuge has been 
given, a glass of the effervescent citrate of magnesia 
is taken. The worm should be passed into a clean 
vessel, containing warm water, and careful examina- 
tion made for the head, for unless this is identified, 
the cure will be unsuccessful. 

This treatment has been so successful in our 
hands, that there has been no necessity to resort to 
less reliable vermifuges, as the pelleterine tannate, 
kousso, kamala, etc. 

Uncinaria Duodenalis. 

{Ankylostomum Duodenale or Hook 

Worm). 

This parasite has assumed a greater interest 
for us in the past few years because of our new 
possessions in the West Indies, and since the pub- 
lication of the investigations of Stiles who has 
shown how prevalent they are in the children of 
the Southern States. 

The hook worms are small thread-like parasites 
with four teeth which enable it to attach itself to 
the intestine. The jejunum being its favorite site. 
The eggs develop rapidly and the embryos are very tenacious of life. 
The eggs are oval in shape, with a distinct capsule and a brownish con- 
tent. Unclean water, the eating of raw vegetables, and unclean hands 
and bare feet are the means through which infection takes place. 

Symptomatology. — The children having hook worms are pasty, 
white and thin. The appetite is abnormal; mainly a craving for the 
unusual. The anemia is marked, so that the patient is listless, without 




Fig. 67.— Unci- 
naria duoden a lis. 
{After Loss, X 105.) 



THE AXIjNIAL PARASITES. 



241 



ambition, and mentally dull. Later the abdomen becomes prominent 
and there is edema of the extremities. The stools if examined show 
the ova. 

Treatment. — Thymol is almost a specific for the hook worm. 
The bowels should be emptied with calomel or castor oil, the diet 
restricted, and thymol given in five-grain doses every two to three 
hours until twenty grains of the soHd drug are taken. Another purge 
should now be administered or a high enema given. Weekly exami- 
nations of the stools should be made, and if any are found, repeat the 
cure each week. Following the elimination of the ova, an iron pep- 
tonate should be prescribed until the hemoglobin content is normal. 




Fig. 68. — Oral capsule of Uncinaria duodenalis. 



Trichina Spiralis. 

Children are liable to infection from this parasite by eating 
diseased pork. Those living in country districts where the curing of 
the pork is done at the farmer's home are especially liable. The 
encapsulated trichinae are freed in the stomach, propagate and deposit 
living embryos. Those which are not passed out of the intestinal 
canal, reach the muscles where they develop and finally become 
encapsulated. 

Symptomatology. — During the first week of their ingestion the 
symptoms are slight and those of a gastrointestinal nature. Then 
general muscular pains with high fever develop and are often mistaken 
for rheumatism or typhoid. Transitory swellings appear. The 
muscles are painful to the touch; nausea and vomiting or diarrhea 
may be present. D5^sphagia prohibits the taking of nourishment. 
Stupor and coma may ensue in fatal cases. Eosinophilia is marked 
and is a distinct aid to the diagnosis. 

Treatment. Prophylactic. — Reliable meat inspection and thorough 
cooking of all hog meat (200° F. are necessary to kill encapsulated 
i6 



242 



DISEASES OF CHILDREN. 






?¥\ 



trichinae) are measures of prophylaxis which are self evident. Better 
still; pork in any form should be prohibited in the dietary of the child. 
Internal. — Calomel is given until free purgation is obtained. 
Benzol is then administered in grain doses, alternating with glycerin 
half a dram every four hours. Good nursing is necessary to keep up 
the strength of the patient through long convalescence. 




Fig. 69. — Encapsulated muscle trichinae. (After Leuckart, X 10.; 



CHAPTER XXI. • 
DISEASES OF THE LIVER. 

The Liver. 

The liver is of relatively large size and functional importance in 
early life. In fetal life it is a very important factor in the circulatory 
system, while the lungs are largely inactive. Thus in the mature 
fetus the liver holds a quarter or more of the entire volume of blood, 
and it is greater in size than both lungs. As the lungs of the fetus are 
solid, and almost impervious, the placenta of the mother performs 
the double function of a respiratory and of a nutritive organ. After 
the venous blood is received from the fetus it must be returned reoxy- 
genated, and nearly the whole of this purified stream is carried to the 
liver by the umbilical vein and circulates through this organ before 
reaching the vena cava and the general circulation. The large size 
and importance of the liver in fetal life are thus understood by con- 
sidering it a sort of intermediary organ between the placenta and the 
general circulation, as far as the reoxygenated blood is concerned. 
At birth the lungs should at once inflate and assume the respiratory 
function. The umbilical vein is completely obliterated in a few days 
and finally becomes the round ligament of the liver and the ductus 
venosus is likewise obliterated. Although the liver now loses its 
preponderating importance in the economy, it still remains relatively 
larger and heavier than in later life. The diminution of the organ is due 
to its altered blood supply, and is especially marked in the left lobe. 
The loss of weight that begins at birth continues, so that there is a 
direct ratio from infancy to old age in this relative diminution. In 
infancy the liver weight is in proportion to the whole body as one to 
twenty; at puberty, one to thirty; in adult life, one to thirty-five; in 
middle life, one to forty; in old age, one to forty-five. 

Examination of the Liver. 

The child is placed in the recumbent position with the thighs 
flexed in order to relax the abdominal muscles as much as possible. 
The organ may then be mapped out by palpation and percussion. 
The liver projects from ^ inch to 1 inch below the free borders of the 

243 



244 DISEASES OF CHILDREN. 

ribs. In the median line the lower border of the left lobe extends to 
within about an inch of the umbilicus. It must be borne in mind 
that the liver ascends and descends with full inspiration and expira- 
tion. If the organ is enlarged it can be detected by deep palpation 
and effort should be made to map out the seat and character of the 
swelling. 

On percussion, liver dullness along the upper border will begin 
at the right sternal margin and in the mammary line in the fifth inter- 
costal space, in the axillary line at the seventh rib, and in the scapular 
region at the ninth rib. Upon very light percussion, the dullness 
will be noted a little below these lines. 

Apparent enlargement of the liver may be caused by a slight 
displacement induced by the bony deformity of the thorax in rickets, 
by effusion in the right pleural cavity, by tumor of the right kidney, 
by fluid in the abdominal cavity, or by subphrenic abscess. The 
commonest causes of true enlargement of the liver in early life are 
abscess, fatty degeneration, cirrhosis, and leukemia. 

Jaundice. 

Icterus neonatorum has been considered in the section on Diseases 
of the Newly-born. In attacking infants some time after birth 
jaundice is due to causes similar to those found in children and adults. 
Owning to some obstruction in the biliary canals, the bile, instead of 
passing into the intestine, is absorbed into the blood. \ 

An inflammation of the duodenum, accompanied by swelhng 
of the mucous membrane at the opening of the ductus communis 
choledochus, may be responsible for this obstruction. The inflamma- 
tion may also extend by direct continuity from the duodenum to the 
ductus communis and hepatic ducts, and thus cause retention of bile in 
the liver. -, 

A plug of inspissated bile in the common duct, and, more rarely, 
gall-stones may also cause obstruction. Complete stoppage has been 
reported by a round worm penetrating the common duct from the 
duodenum. 

Inflammatory changes in the liver, as in cirrhosis, may induce 
jaundice by obstruction from pressure in the intrahepatic ducts. 
Finally, certain toxic conditions, as in paludism and various 
infectious diseases, and rarely phosphorous poisoning may act as 
causes. 

Symptomatology. — The most objective sign is the general yellow- 
ness of the skin and the conjunctivae. Other abnormal tints of the 



DISEASES OF THE LIVER. 245 

skin simulating jaundice may be differentiated by the yellow conjunc- 
tivae and by the presence of biliary pigment in the urine. 

Itching of the skin may be present. Urticaria, which is so com- 
mon in children, sometimes ensues when the papules and wheals will 
present a deep-yellow tint. The yellowness of the skin is usually only 
to be noted in a natural light. 

The most marked internal symptoms may be those that can be 
referred to a duodenitis or a gastroduodenitis. In the latter case 
there is more or less nausea and vomiting, with jDain in the epigastrium, 
especially upon the ingestion of food and tenderness upon pressure 
in this region. 

There may be a subacute duodenitis without gastritis being 
present, when pain will be noted some hours after taking food as it 
passes from the stomach into the duodenum. / The stools may be clay 
colored from an excess of undigested fat when no bile reaches the in- 
testine./ When the obstruction to the passage of bile is only partial 
the stools may retain a natural brownish-yellow color. The complete 
absence of bile will be shown by a quick decomposition of the intestinal 
contents as exhibited in the free formation of gases and a foul odor of 
the feces. / 

The pulse may be slow as the biliary salts have a sedative effect 
on the circulation. Most cases of jaundice in young children disap- 
pear in a few weeks without leaving any serious consequences, but 
rarely there may suddenly ensue evidences of blood-poisoning, 
followed by death./ Occasionally the jaundice will last for months 
without giving rise to much apparent disturbance except a slight 
stupidity. 

Treatment. — Where there is no evidence of gastroduodenal in- 
flammation, active . peristaltic action in the duodenum to be trans- 
mitted to the bile ducts may be induced by calomel, rhubarb, aloes, or 
colocynth. This may be followed by a mixture containing tincture 
nucis vomicae with bicarbonate of potassium or sodium, as alkahes are 
supposed to have a liquefying effect upon the bile, thus freeing the 
ducts when they are occluded by a thickening of this secretion. 

Only bland and easily-digested food must be allowed. All fatty 
foods must be restricted and the patient kept on lean meat and plain 
vegetable food. 

When the jaundice depends on a subacute inflammation of the 
stomach and duodenum, the saline laxatives and mineral waters do 
well. Carlsbad, Vichy, and Congress waters usually are beneficial. 
Persistent constipation is one of the commonest symptoms, and must 
alwavs be relieved. 



246 DISEASES OF CHILDREN. 

Inflammation of the Biliary Ducts. 

An ordinary acute inflammation of tlie biliary ducts usually under- 
goes resolution in a few weeks without any bad results being left behind. 
As a result of the inflammation a collection of mucus, often taking 
the form of a firm plug, is located at the opening of the common duct 
into the duodenum, thus causing more or less complete obstruction. 

In chronic cases there may result a thickening of the ducts, with 
dilation in places caused by the obstructed secretions. Rarely, ulcera- 
tion may take place in the walls of the ducts. The mucous membrane 
of the gall-bladder may likewise be the seat of inflammatory changes. 

Symptomatology. — Various digestive disturbances shown by 
coated tongue, nausea or vomiting, and other symptoms pointing to a 
mild inflammation of the stomach are present at the start. There 
may be slight fever. 

In a few days the conjunctivae become yellow, the urine is colored 
by biliary pigment, and the feces assume a clay-like appearance. 
There may be a slight enlargement of the liver and the gall-bladder 
may be palpated. There may be some tenderness on pressure over 
the right hypochondrium. When the inflammation of the ducts is 
secondary to congestion of the liver, there is less digestive disturbance 
and milder jaundice of shorter duration. 

The treatment is the same as that of jaundice. Where the inflam- 
mation is induced by changes in the parenchyma of the liver or by certain 
infectious diseases, treatment must be aimed at the underlying cause. 

Inflammation of the Portal Vein. 

Suppurative pylephlebitis may occur as a secondary lesion result- 
ing from suppuration in some of the organs drained by the portal 
vein or its radicles. Ulcerations of the gastrointestinal mucous mem- 
brane, inflammation or ulceration of the biliary duct and umbilical 
phlebitis in new-born infants whose mothers are septic may spread 
to the portal system and set up inflammation there. 

Symptomatology. — ^Local pain in that part of the portal vein 
involved will follow the symptoms of the primary morbid condition. 
Enlargement and tenderness of the liver may be due to a general hepa- 
titis or to abscesses. The spleen may hkewise become enlarged and 
tender from occlusion of the splenic vein. As pus forms in the portal 
vein, there will be chills, fever, sweating, and general emaciation. 
Intestinal indigestion with bilious stools and jaundice usually are 
present. Although there may be remissions, the disease usually ends 
fatally in a few weeks. 



DISEASES OF THE LIVER. 247 

Treatment. — All that can be done is to treat symptoms as they 
arise and sustain the strength as muth as possible. 

Organic diseases of the liver are rare in early life and do not differ 
essentially from adult life. 

Congestion of the Liver. 

This condition may be active or secondary. The active form 
occurs during certain infectious diseases, especially paludism, and in 
the early stages of abscess of the liver. The secondary form is seen in 
affections of the heart and any other physical condition which causes 
stagnationin the liver by checking the access of blood to the ascending 
vena cava. 

The organ is enlarged in both form.s, but more so in the cases of 
passive hyperemia. There is usually tenderness on pressure over the 
region of the liver. 

The treatment must be addressed to the disease or local condition 
that causes the congestion. Phosphate of sodium, citrate of magne- 
sium, and other saline purgatives may be given to try and deplete the 
portal circulation. 

Fatty Liver. 

This condition may be present in various constitutional diseases, 
especially rickets and tuberculosis. It is more often secondary to the 
latter disease than to any other. Chronic intestinal disorders and 
blood dyscrasias may also act as causes. 

The organ is generally uniformly enlarged. In some cases the 
increase in size is very great, but tenderness is absent. There are usu- 
ally no symptoms, and treatment of the original disease is all that can 
be accomplished. If there is little enlargement, the condition cannot 
be recognized during life, but it is seen to some extent in a large num- 
ber of the autopsies made on young children. 

Amyloid Liver. 

Waxy liver is secondary to prolonged suppuration in any organ, to 
chronic joint or bone disease, to tuberculosis or syphilis. The liver is 
generally enlarged, with a hard, rounded border and free from pain on 
pressure. On section, it gives a reddish-brown reaction with iodin. 
Similar changes also usually develop in the spleen and kidneys, and 
the spleen is thus enlarged. There are no distinctive liver symptoms 
or jaundice. Albuminuria may be present from the kidney affection, 



248 DISEASES OF CHILDREN. 

and ascites or edema from pressure. Gastrointestinal irritation, 
shown by vomiting and the passage of foul-smeUing stools is often 
noted. When waxy liver is recognized, it means some form of chronic 
disease and a grave prognosis. 

The treatment consists in trying to check the original focus of 
suppuration, in supporting the patient, and in handling various symp- 
toms as they arise. 

Cirrhosis of the Liver. 

This disease is rare in early life and is oftener accompanied by 
enlargement than contraction of the liver. The commonest primary 
causes are syphilis, alcohol, and chronic paludism. Syphilitic cirrhosis 
is seen in early infancy, and is perhaps the commonest form of organic 
disease of the liver at this time. When alcohol acts as a cause, it is in 
older children of from ten to fifteen years of age. In chronic malarial 
poisoning, there is great enlargement of the liver when this organ is 
the seat of cirrhosis. There may be secondary cirrhosis, as in adults, 
from hepatic hyperemia due to chronic cardiac disease, from prolonged 
obstruction of the bile ducts, and possibly from infectious diseases, such 
as measles and scarlatina. 

The pathology and symptoms do not differ from cirrhosis seen in 
later life. It is often difficult to recognize the disease apart from the 
general condition, such as syphilis, that produces it. There may be no 
symptoms directly referable to the liver. Icterus may or may not 
be present, but enlarged spleen and ascites are common. 

The treatment must be directed to the primary disease and various 
symptoms as they arise. 

Abscess of the Liver. 

Abscess may follow suppuration within the abdomen, very 
rarely from the migration of round worms through the common duct, 
from infectious diseases, and in the newly-born from sepsis. It is 
very rare, however, and the symptoms are similar to those seen in the 
adult. The treatment is surgical. 

Acute yellow atrophy and gall-stones occur with very great 
rarity in early life, and do not differ in course and symptoms from the 
same affections in the adult. 



SECTION YI, 
THE INFECTIOUS DISEASES. 



CHAPTER XXII. 
THE EXANTHEMATA. 

The exanthemata consist of five diseases: scarlet fever, measles, 
German measles, small-pox and chicken-pox. All except small-pox are 
distinctively diseases of childhood; although any of them may occur 
in adults. Each runs a definite self-limited course, subject to varia- 
tions and complications. As a rule, each renders an individual im- 
mune to future attacks of the same disease, but one does not confer 
immunity from another. Two of them may occur in the same individ- 
ual at the same time. Each is divided into four stages: the stage 
of incubation, prodromal stage, efflorescence, and desquamation. 

The stage of incubation comprises the interval from the time when 
the contagium is taken into the system until the first s^miptoms appear. 
The prodromal stage is the period included between the appearance 
of the first symptoms and the appearance of the eruption. The stage 
of efiiorescence extends from the time of the first appearance of the 
eruption until it fades and the stage of desquamation begins. As the 
great majority of cases run a typical course, such a form of the disease 
will first be described, always bearing in mind that the many varia- 
tions and comphcations which are later described may alter the general 
picture. 

Measles. 

{Rubeola, Morhilli.) 

Definition. — Measles is an acute contagious disease characterized 
by a period of incubation, a prodromal stage with fever, coryza, lacri- 
mation, cough, and Koplik's spots, follow^ed by a red, papular erup- 
tion and a fine desquamation. 

Etiology. — No specific microorganism has as yet been discovered. 
The contagium is contained in the nasal, lacrimal, and bronchial secre- 
tions and, unlike scarlet fever, to a less extent in the desquamated epi- 
thelium. It has been transmitted through direct inoculation of the 
nasal secretions and blood. It is, therefore, more contagious in the 
early stage. The contagion extends through the eruptive and desquam- 
ative stages. It has not the property of clinging tenaciously to such 

249 



250 DISEASES OF CHILDREN. 

objects as clothing, and it is doubtful if it is often carried by a third 
person; surely not as easily as scarlet fever. Epidemics spread rapidly, 
owing to its transmission on short exposure and to its highly contagious 
character before the diagnostic eruption appears. Most people have 
the disease at some time during life; therefore, adults are not immune 
unless they have already had it. It is most frequent between the first 
and sixth years; rare before the fifth month, and only 5 per cent, of 
the cases occur under one year. It has occurred at birth. One attack 
usually protects the individual from further attacks,! but recurrences 
are more common than in any of the other exanthemata. It occurs in 
all countries and at all seasons. 

Pathology. — The skin shows an infiltration of round cells which 
surrounds the sweat and sebacious glands as well as the capillary 
blood-vessels which are found distended with blood. The mucous 
membranes show inflammatory changes. Other pathological con- 
ditions, such as bronchopneumonia, are not typical of measles. 

Incubation. — Eight to twelve days; usually ten days. 

Prodromal Stage. — Three to five days; generally four days. 
The onset is not usually as abrupt as in scarlet fever. The child 
appears to have a cold in the head, has some cough, and a temperature 
of 100° F. to 104° F., according to the severity of the disease. There is 
not apt to be vomiting, nor are convulsions common, although either 
may occur. The coryza gradually increases, lacrimation and the 
nasal discharge become more profuse, the child grows sicker, and 
finally the face assumes the puffy appearance with redness about the 
nose and eyes commonly seen in a severe coryza. Very often a decep- 
tive fall in temperature with seeming improvement of the child's gen- 
eral condition takes place on the second day, only to be followed the 
next day by a further rise of temperature and increased symptoms, 
which continue to increase until the eruption is at its height. There 
may be in some cases a regular remittent fever during the three or 
four days of the invasion. Koplik's spots which are pathognomonic 
of measles, and almost invariably present, are found on the mucous 
membrane of the cheeks and lips all through the prodromal stage 
if inspected in strong sunlight. The first day there are usually less 
than six of these rose-red spots scattered over the pink mucous mem- 
brane, in the centre of which are bluish-white specks. Some are minute, 
about one-eighth of an inch in diameter. Soon they may increase in num- 
ber until they coalesce and lose their characteristic appearance as the 
exanthem comes to its height. Koplik's spots are to be differentiated 
from the rose colored papules with superimposed whitish vesicles seen 
on the soft and hard palate in German measles, scarlet fever, and 



THE EXANTHEIMATA. 251 

simple angina, as well as in measles. A redness of the fauces and phar- 
ynx said to resemble the characteristic eruption on the skin is generally 
seen. 

Eruption. — On the third or fourth day the exanthem appears on 
the face in the form of discrete, raised, red, pin-head-sized papules. 
They are sometimes arranged in crescents. The eruption spreads to 
the neck, chest, back, and arms, and within thirty-six hours the whole 
body, including the palms and soles, is involved. While spreading 
thus, the papules on the face are enlarging peripherically until they 
become confluent and large areas are covered, with only here and 
there small areas of intervening normal skin. This process takes 
place also on the rest of the body in the order in which the eruption 
originally appeared. The whole face is swollen and has a character- 
istic mottled ai3pearance w^hen the eruption is at its height. The lids 
are red and edematous, and the conjunctiva inflamed, tending to keep 
the eyes half-closed. Photophobia is pronounced. This condition is 
usually reached within thirty-six hours after the first appearance of the 
eruption, and continues together with the maximum temperature, 
coryza and cough, for one or two clays. During the next two days 
the eruption fades and the temperature falls, so that within seven or 
eight days from the onset of the first symptoms, the temperature is 
normal and desquamation is taking place. 

Desquamation begins in the order in which the eruption appeared, 
often beginning on the face as the exanthem has reached its height 
on the limbs. It consists of fine flakes unlike the large lamellae of 
scarlet fever. It is completed in one or two weeks. 

Variations, Complications and Sequella?. — The incubation may 
last as long as twenty-one days. There may be no symptoms of rhini- 
tis or bronchitis whatever, throughout its course. Relapses, i.e., 
recurrences of temperature and eruption are very rare, but may occur 
a few days after the temperature has become normal. 

Fever. — There are afebrile cases and cases with hyperpyrexia, but 
neither are common in uncomplicated measles. The remission of tem- 
perature on the second day of the prodromal stage may not occur, but 
the majority of cases show it. A continued temperature after the 
eruption subsides, or a persistent rise of temperature during the first 
or second week of convalescence always leads us to suspect com- 
plications, particularly bronchopneumonia or middle-ear infection. 

Exanthem. — Occasionally the eruption itself is so atypical that 
a diagnosis can only be made by a general consideration of the other 
features of the case. Rarely it may be erythematous or even vesicu- 
lar in character, or the papules may be very large or macular from 



252 DISEASES OF CHILDREN. 

the first. They may vary from the typical red color to purple or, on 
the other hand, they may be very faint pink. There may be minute 
hemorrhagic spots about the papules even in benign cases; or in the 
severe toxic and often quickly fatal cases the hemorrhagic areas are 
extensive and simultaneous hematuria and epistaxis occur. In 
weakly children the eruption is often very limited even in severe 
cases. It may vary in the order of its appearance coming simultane- 
ously upon the face and thorax, or even on the thorax or abdomen 
first. It may subside entirely in twenty-four hours. Entire absence 
of the eruption is very rare, if it occurs at all. ' 

Lungs. — Here we find the most common and the most dreaded 
complications of measles. A mild bronchitis with coarse mucous rales 
throughout the chest is very common during the early stage, and may 
pass off with the eruption. But often this outcome is not so fortunate, 
for it may continue into a chronic bronchitis; or while the disease is at 
its height the respirations may become more rapid, localized areas 
of fine crepitant rales appear, and bronchopneumonia may develop. 
Its course differs in no way from the ordinary bronchopneumonia, 
being the cause of death in the great majority of fatal cases. It may 
occur at any time between the beginning of the prodromal stage and the 
completion of desquamation. Lobar pneumonia is seen less frequently. 
The above-mentioned conditions of the respiratory tract make good 
soil for the growth of the tubercle bacillus, so that measles is one of the 
most frequent sources of pulmonary tuberculosis in childhood. Un- 
resolved pneumonic areas and continued cough and bronchitis should 
receive prompt attention, and the physician should have this com- 
plication constantly in mind. 

Pertussus from previous exposure is considered a very serious 
complication. Pleurisy and empyema are less common complications. 

Nose, Pharynx, and Larynx. — The inflammatory conditions here 
may cause enough obstruction to lead to much difficulty in feeding 
or in breathing. 

Spasmodic croup, a pseudomembrane of streptococcic origin or a 
double infection with the diphtheria bacillus may complicate the 
case. Diphtheritic croup complicating measles is very fatal owing to 
the rapid descent of the pseudomembrane into the bronchial tubes. 
Ulceration of the larynx may cause great edema with extreme dys- 
pnea or subsequently the scar may cause a serious stenosis of the 
larynx. 

Ear. — The external auditory canal may be painfully swollen 
through extension from the skin. Otitis media is often of a mild 
grade when due to infection through the blood, but severe cases are 



THE EXANTHEIVIATA. 253 

due to extension through the Eustachian tube. Mastoid disease has its 
usual relation to the otitis media. 

Eye. — Conjunctivitis is of the usual type in a more or less severe 
form. Keratitis and iritis may result and do permanent damage to 
the eye. Any previous condition may be rendered more active. 

Other Organs. — The intestines are occasionally involved, and 
the resulting diarrhea is often severe. Stomatitis may occur from the 
same source. Cerebrospinal meningitis is occasionally seen, particu- 
larly in the pneumonic cases. The heart and kidneys are rarely 
affected in uncomplicated measles, although the kidneys may show 
transient abnormalities through the urine. Osteomyelitis and suppu- 
ration of the joints have been seen, but are rare. 

Prognosis. — The mortality from measles itself is not high, but 
the pulmonary complications render it one of the most serious of chil- 
dren's diseases. Fatal cases almost invariably show bronchopneu- 
monia or less frequently lobar pneumonia. The mortality averages 
8 to 10 per cent., and is greatest during the first year. Epidemics 
in institutions often give a high mortality. 

Prophylaxis. — Measles is by no means a mild disease. Through 
its complications it is productive of many deaths. All possible pre- 
cautions should be taken against the exposure of infants, especially 
those under three years of age. Isolation should be carried out just 
as soon as the disease is suspected and should last at least three 
weeks. Children who have been exposed should be kept segregated 
from other children for that period. 

Treatment. — Hygienic and hydrotherapeutic measures are of 
greater importance than the medicinal treatment. Select a well- 
ventilated room that is as far as possible from direct communication 
with the rest of the house. The light should be thoroughly subdued 
with dark shades until all photophobia is past. If the fever is high 
and causing ill effects, such as delirium, it can be controlled by spong- 
ing with luke warm water and by frequent drinks of cool water. If 
a sedative seems necessary, small doses of phenacetin will have the 
desired effect (one grain for a two-year-old child every two hours 
for four doses). ^ The cough in the early days of the eruption is often 
troublesome and prevents sleep. Small doses of the bromid of sodium 
with chloral may be given for its conrol. (Four grs. bromid with one 
gr. chloral every four hours for a child of five years or codein phosphate 
Yt oi a grain for one or two doses.) Ammonium chloric! and 
sweetened cough mixtures only tend to produce an irritable stomach 
and consequent anorexia. The e^^es should be bathed with 4 per cent, 
boric acid solution. In some cases there is considerable itching of the 



254 • DISEASES OF CHILDREN, 

skin, and this may be relieved by inunctions of 5 per cent, ichthyol 
and lanolin. The bowels are kept open preferably with small doses of 
calomel or enemata. The ears should receive careful daily inspection 
for any redness or bulging, and if present an aurist may then elect to 
do incision and drainage of the ear drum. By careful attention to the 
eyes, ears, and nasopharyngeal toilet, many of the disastrous com- 
plications of measles may be avoided. Bronchopneumonia, as a rule, 
supervenes more often in those cases that have been treated by sweat- 
ing and administration of hot drinks, thus further lowering the resist- 
ance of the child. 

German Measles. 

{Rotheln, Rubeola.) 

Definition. — German measles is a mild acute contagious disease, 
having a period of incubation, a prodromal stage followed by a red 
macular eruption and desquamation. It is attended by little if any 
systemic disturbance. 

Etiology. — There is no known specific microorganism. The 
disease spreads with great rapidity, the contagium taking place on 
slight contact. It is conveyed by direct contact, and is probably not 
carried by a third person. One attack usually protects, but it has 
occurred in the same individual a number of times. Neither scarlet 
fever nor measles render immunity, as it seems to bear no relation to 
these diseases. 

Pathology. — There is no specific pathology. 

Symptomatology. — After an incubation of between two and three 
weeks, during which there are no symptoms, a slight cor3^za or sore 
throat develops with a temperature rarely over 101° F. In a great 
many cases these prodromal symptoms are wholly lacking, and in 
about 50 per cent, there is no temperature at any time. There is 
rarely more than a slight indisposition and loss of appetite. ' On the 
first or second day the eruption appears. \ Often a premonitory gen- 
eral blushing of the skin fading in a few hours with small discrete 
macules, deep pink in color, are seen on the face. 

These rapidly spread to the thorax, and thence within twenty-four 
hours to the rest of the body, but they are much more numerous on the 
face than elsewhere. The eruption never reaches its height in all parts 
of the body at the same time, as it begins to fade on the face before the 
extremities are reached. The throat is reddened. If there has been 
any fever it disappears soon after the eruption comes out. In two to 
four days the eruption has faded, and a slight brownish staining of 



PLATE VII. 






Rubella (German measles). 



THE EXANTHE]\L\TA. 255 

the skin, with shght desquamation, is at times seen. '^ The posterior 
and occipital lymph nodes are very constantly enlarged, even before 
the appearance of the eruption, and confirms the diagnosis. * 

Prognosis. — Recovery after a short mild course is to be expected. 

Treatment. — This is, as a rule, mainly symptomatic. Beyond a 
liquid diet and sponging with alcohol very little is required. In 
severer cases the treatment given under Measles may be appropriately 
followed. The children are isolated for a period of two or three weeks, 
and their surroundings should be such as described under Measles. 

Scarlet Fever. 

{Scarlatina.) 

Definition. — Scarlet fever is an acute infectious, and contagious 
disease, characterized by a sudden onset, vomiting, and a generalized 
scarlet rash, accompanied by high fever. 

Incubation. — Varying periods of incubation are recorded. In 
our experience two to seven days after exposure the symptoms appear, 
The German authors give an incubation period from eight to eleven 
days. 

Etiology. — The specific causative factor is still unknown. It 
occurs more often between the ages of one to five. The incubation 
period is the least contagious, while the eruptive stage is the most 
contagious. The stage of desquamation was formerly considered the 
period of greatest danger. One attack, as a rule, protects the individual 
from subsequent attacks. The immediate neighborhood of the pa- 
tient is probably a contagious zone. The secretions, as the urine and 
feces, clothing, and desquamated epithelium are the agents that seem 
to distribute the infection. They may retain this power of infection 
for months and even years. 

Pathology. — The lesions found vary greatly with the intensity of 
the infection, and are due to the action of the scarlatinal toxin (strep- 
tococcic) or to a mixed infection. The heart muscle, and the kid- 
neys show degenerative changes. The cervical glands are found 
hypertrophied. 

Symptomatology (Simple Form). — Vomiting is usually the first 
symptom. Convulsions may usher in the disease in younger children. 
The child has fever and within twenty-four hours the rash appears, first 
upon the neck and chest. It is bright in color, diffuse, pin-point, with 
no areas of healthy skin in between; it rapidly spreads downward to 
the arms, trunk, and legs. The face is not as much affected as the rest 
of the body. Sometimes hardly any rash appears there. The rash 



256 DISEASES OF CHILDREN. 

is accompanied by a variable amount of pruritus. The tongue is 
coated quite heavily and often has the so-called raspberry appearance, 
due to the injection of the papillae. Later the tongue takes on a red 
beefy appearance when the coating disappears. The fauces and tonsils 
are congested. The fever ranges from 102° to 104° F., with a rapid 
pulse. The glands in the cervical region are tender and often become 
swollen, especially in the later stages of the disease. The urine will 
show traces of albumin, which is often temporary only. It is apt to 
be scanty and high colored. 

The blood shows a leukocytosis, while a differential count may 
assist in the diagnosis by showing an increase in eosinophiles quite 
early in the disease. 

Desquamation. — This begins with the fading of the rash about the 
second or third day. The skin appears in fine scales usually seen first 
on the face and about the joints, then over the body. On the hands 
often large sections of skin are shed. The process lasts many days, 
sometimes weeks, but can generally be assisted by the treatment given 
below. 

Anginal Form. — The tonsils and retropharynx are congested. 
The tonsils may show exudation in their lacunar spaces, and the cervical 
lymph-glands are much enlarged. In another form, a membrane 
may be present on both tonsils spreading to the adjacent fauces, and 
gave rise to the false term of diphtheritic scarlet fever. It is due to a 
streptococcic infection, and should be regarded as the septic form of 
this disease, as in these cases there is always more or less general 
systemic infection. 

The fever in this form is usually of a remittent character and will 
be influenced by any complications that may arise. The severe 
forms cause prostration, stupor, or profound coma. The temperature 
remaining about 105° F. with rapid pulse. The urine is scanty. 
Deglutition is extremely difficult. There is marked restlessness. 
The membrane may invade the nose or larynx, the lips are fissured and 
the breath is extremely fetid. 

Routine examination of the ears will often show some degree 
of involvement in more than a fifth of the cases; if the patient goes on 
to recovery the lymph-glands degenerate with the formation of ab- 
scesses. Meningeal symptoms may precede the fatal issue. 

The mastoid cells may become diseased after convalescence has 
set in. Septic thrombosis and cerebral abscess are fortunately rarer 
complications. The otitis media of scarlet fever may persist, and be 
the cause of partial or absolute deafness. 

Kidneys. — Modern methods of urine examination will show 



THE EXANTHEAIATA. 257 

traces of albumin and a few hyalin casts even in mild attacks. This 
should not be regarded as a true nephritis. The septic form of 
the disease through the agency of its toxins is more likely to be com- 
plicated by a true nephritis. 

Puffiness of the^ eyelids and face, edema about the ankles spread- 
ing to the rest of the body will be the first objective signs. The urine 
then persistently contains albumin and mixed casts, with a high speci- 
fic gravity. The nephritis usually lasts through a protracted convales- 
cence or may become chronic. Uremic symptoms begin with vomit- 
ing or convulsions, sometimes only convulsive movements are 
observed. Coma with feeble heart action are symptoms of grave peril. 

The Rash. — The development of the rash, usually after twenty- 
four to forty-eight hours, offers considerable information of value in 
differentiating scarlet fever from the confusing erythematous eruptions. 
The examiner should place his patient in a good white light. A magni- 
fying glass and a glass slide, such as is used for blood and sputum, will 
be found to be exceedingly helpful in studying the exanthem. The 
rash first makes its appearance on the sides of the neck, upper part of 
the chest and face; thence spreads to the arms, upper part of the back, 
and finally involves the trunk and lower extremities. Its color is not 
scarlet, but a dull red, almost a brownish-red (Fig. 3, Plate IX). 
This color varies proportionately to the fever, being more marked 
usually in the evening. The general characteristics of this rash about 
to be described, will always be found present in a true case of scarlet 
fever, even though certain modifications or variations are observed. 
Close inspection of the rash resolves it into two factors, which are con- 
stantly present: 1. An erythematous background; 2. small, deep 
red, injected puncta (Fig. 5, Plate IX). Sometimes variations in 
the rash just described are present which give a diffuse, a mottled, or a 
speckled appearance. These changes are caused either by the closer 
merging or by the non-extension of these puncta with their erythe- 
matous areola. A normal or pale flesh tint is seen on pressure with a 
glass slide early in the disease, while later there is a dirty, yellowish- 
red pigmentation. Itching is quite a constant symptom, but is more 
marked when many groups of miliary vesicles are present. At the 
height of the eruption, it is often possible to find small pin-point, 
conical, whitish vesicles, with a serous content over the chest and lower 
abdomen (Fig. 1, Plate IX). When they occur in groups about the 
axillae or in the groins, they are quite confirmatory from a diagnos- 
tic standpoint. The harsh, uneven feel which the rash occasionally 
gives to the hand passed over the skin, is due to papular or even vesicu- 
lar elevations occurring at the sites of the hair follicles. This papula- 

17 



258 DISEASES OF CHILDREN. 

tion affords another valuable aid, as it does not disappear with the 
erythematous rash, but the roughness of the skin persists after it has 
faded. 

Certain regional characteristics are present in this exanthem, 
which, if appreciated, tend to help the puzzled physician. The face, 
for example, shows the true rash only on the temples; the cheeks are 
profusely red, but the nose, chin, and upper lip appear unduly pale, 
causing a circum-oral pallid ring which should be sought for in sus- 
pected cases, as it is not present in the counterfeiting rashes. 

The flexor surfaces of the joints deserve careful scrutiny and 
special mention. These regions rarely exhibit the characteristic rash; 
they are apt to be the site of petechial hemorrhages or else they have 
a blotchy appearance. 

If the palms and soles are examined with the magnifying glass, 
no puncta are seen, only a simple erythematous blush. 

Desquamation. — In the exfoliation of scarlet fever we expect to 
find it occurring in the order of the appearance of the exanthem. At 
first there are observed fine discrete scales in the infraclavicular and 
episternal regions (Fig. 6, Plate IX). These scales are made up of 
the epidermal covering of the above-described puncta and vesicles. 
When desquamation first occurs flakes having a perforated center 
are cast off. This is known as '^pin-holing." Later, and continuing 
for five to seven weeks, the skin becomes rougher, throwing off irregu- 
lar rings of desquamation of varying extent. The large strips of 
epithelium and casts of the hands and feet which are sometimes shed 
or torn away are more often seen in those subjects who have a skin of 
coarse texture. 

Another diagnostic feature of this stage of desquamation is seen 
in the finger-nails. If "the pulp is pushed back from the nail, there 
will be seen just beneath its free border, a scaling or cracking line 
which extends up to the fingers. Four to five weeks after the begin- 
ning of the disease, we may find a transverse linear groove sometimes 
with a corresponding ridge, which shows itself on the roof of the nail. 
The thumb-nail exhibits this condition better than the fingers. These 
nail changes serve as corroborative evidence in the subsequent diagno- 
sis, and this desquamation may be seen on the nails when other evi- 
dences are not found elsewhere. On the other hand, it must not be 
forgotten that the desquamation may be so slight as almost to escape 
notice. Unfortunately, desquamation alone is often regarded as 
sufficient evidence of the disease, and a diagnosis is based thereon. 
In view of the fact that so many of the erythematous eruptions produce 
skin exfoHation, we are not justified in this conclusion, unless we have 



PLATE VIII. 





Rash of scarlet fever. 



THE EX.\XTHE]MATA. 259 

1. the regional involvement; 2. the pin-holing, and 3. the nail changes, 
plus other pertaining clinical symptoms. 

The Tongue. — The tongue in the first days is usually thickly 
coated, and the papillae are obscured, but as the tongue clears up at 
the edges and tip, we can observe the enlarged papillse (Fig. 4, 
Plate IX) which become more and more prominent, and show at their 
best about the fourth day. The lingual mucous membrane now be- 
gins to exfoliate; the tongue becomes red, dry, and glistening. It is in 
the posteruptive stage that this feature is particularly of diagnostic 
importance. 

The Blood. — The blood in scarlet fever has been carefully studied, 
and may be of service in obscure cases, as an additional confirmatory 
link. The red blood-cells are gradually diminished throughout the 
course. A leukocytosis is present a day or two before the appearance 
of the rash, and the normal is regained only in convalescence. We 
have found this leukocytosis to be proportionate to the severity of the 
angina. The polynuclears are increased and the mononuclears de- 
creased, both relatively and absolutely. To the eosinophiles we miay 
look for some rather characteristic variations. In the initial stages 
they may disappear almost entirely, while in defervescence, and later 
to the sixth or seventh week, 8 to 12 per cent, may be counted. 

Differential Diagnosis. — The Erythemata. — Erythematous erup- 
tions which may simulate the rash of scarlet fever are quite common; 
and if a careful examination and study of the rash is not made, weigh- 
ing with it all the clinical evidence, mistakes are easily made. The 
simple form of erythema results from external irritants, while the 
exanthem of angioneurotic origin results either from systemic disturb- 
ance, ingestion of certain drugs, or from specific poisons. These for- 
tunately have certain characteristics which should be borne in mind, for 
while we are not always able to distinguish them one from the other, 
the differentiation from scarlet may be thus made possible. 

One of the striking features is the tendency to recurrence, and 
undoubtedly many of the so-called second and third attacks of scar- 
latina have been in this class. In a general way these dermatoses 
are distinguished by' the following peculiarities: They may appear 
in any region of the body — at one time there may be present in the 
erythema elements of the various exanthemata. Their type may 
rapidly change so that they may be scarlatiniform one day and mor- 
billiform the next. The puncta seen in the scarlet fever exanthem 
/3.re absent. Desquamation is coarse and flaky, and recurrences are 
frequent. 

Erythema Scarlatiniforme. — This is a non-contagious derma- 



260 DISEASES OF CHILDKEN. 

titis, simulating scarlet fever in its cutaneous manifestations. It is 
liable to occur secondarily to other infectious diseases and to medici- 
nal and food intoxication. As it is important to differentiate the 
disease from scarlatina^ its distinguishing features will therefore be 
given. 

This erythema spreads very rapidly, sometimes reaching its 
height in a few hours. Patches of erythema may alone be present. 
Under the glass there is no uniform redness. The face is rarely in- 
volved and the tongue shows no "raspberry" appearance. The fau- 
ces may be red but are not swollen. Desquamation takes place at an 
early date after the erythema/ sometimes on the second day; it is a 
quick process and the scales are large, abundant, and furfuraceous. 
The course is brief, and there are no complications or sequelae. Such a 
clinical picture, especially in a child who has given a history of previous 
similar attacks, should exclude scarlatina. A scarlatinoid erythema 
may follow the use of such drugs as belladonna, quinin, chloral, chlore- 
ton, salicylic acid, antipyrin, digitalis, opium or veronal, especially 
in those patients having a drug idiosyncrasy. These eruptions 
almost invariably follow very quickly after the ingestion of the drug. 
We have seen it occur within an hour after a dose of antipyrin. The 
close relationship to the drug taking, is a diagnostic feature of consider- 
able value. Belladonna rashes are perhaps most often seen. This 
eruption is usually confined to the face, neck, and chest, and is only 
rarely generalized. It fades quickly and is rarely followed by any des- 
quamation. The absence of fever, the dilated pupils, the evanescent 
rash and the history should cause no confusion. 

It is well to recollect that drug rashes in general, and in contrast 
to scarlet fever, appear for the most part on the extensor surfaces 
of the extremities, and if they be present on the face, then the circum- 
oral ring is not observed. Moreover, they are not associated with 
fever, angina, or adenitis. If any doubt still exists, the repetition of 
the dose of medication under suspicion should be given to reproduce 
the erythema. 

Acute Exfoliative Dermatitis. — Another disease which may 
raise a veritable doubt in the stage of efflorescence or in the desquama- 
tive period is acute exfoliative dermatitis. It differs in that the consti- 
tutional symptoms are more pronounced than in scarlatinoid ery- 
thema, while the eruption appears as a general hyperemia very soon 
covering the entire body. The exfoliation follows in a day or two, and 
is general in character and intensely profuse; large papery strips being 
cast off (Fig. 8, Plate IX). The nails and hair may drop out before 
the process is complete. 



PLATE IX. 




The differential diagnosis of scarlet fever and the Scarlatiniform eruptions. 
1. Scarlet fever rash showing sudaminal vesicles. 2. The fading scarlatina 
eruption. 3. Scarlatina eruption, early stage. 4. Typical scarlet fever tongue. 
5. The scarlet fever rash, magnified. 6. Scarlet fever desquamation. 7. The 
scarlatinal form of rubella. 8. Acute exfoliative dermatitis. 9. Erythema in- 
fectiosa. (Pisek's original plate; courtesy Archives of Diagnosis.) 



THE EXAXTHEAL\TA. 261 

Another disease which necessitates correct interpretation is the 
scarlatiniform variety of rubella; fortunately, this is not a common type 
(Fig. 7, Plate IX). Close inspection of the rash will disclose morbilli- 
form characteristics. The mild constitutional symptoms and the 
enlarged postcervical glands of rubella will define it. 

Serum Rashes. — The use of antitoxic serum may be productive 
of a scarlatinoid rash that is very puzzling. This is especially true 
when antidiphtheritic serum has been injected. The angina of the 
diphtheria is already present and cannot assist us, while fever and 
malaise supervene. We must then depend upon the following facts: 
That the rash frequently spreads from the site of the injection; that 
these rashes are often polymorphous in character and fleeting in 
duration. They appear on the third or fourth day, the eruption occurs 
usually in patches and only rarely appears on the face. A well-marked 
enlargement of the superficial lymph-glands in the inguinal, axillary, 
and epitrochlear regions will also help to distinguish this rash from 
scarlatina. 

Open wounds and especially burns are liable to direct inoculation. 
Many of the so-called cases of ''surgical scarlet" of the older writers 
were probably scarlatinoid erythemas or what we now recognize as 
septic rashes. \ For our guidance in differentiation the wound is of 
considerable help; an erstwhile healthy wound may begin to look un- 
healthy, and an exudate may form upon it. The rash is very likely to 
first appear at or near the wound. 1 The nearest lymphatic nodes 
will be found tender and enlarged. I Vomiting may occur, but sore 
throat is rarely complained of.* There are no characteristic changes 
in the desquamation. 

The septic rashes which were referred to above, occur more often 
in early life, and either precede or accompan}^ a definite septicopyemia. 
Occasionally they may indeed be the first to call attention to the true 
condition of the patient. When the rash is small and macular, it may 
resemble scarlet fever. Its spotted character and the large macules 
which are seen on the extensor surfaces of the extremities with ab- 
sence of puncta fix the diagnosis (Fig. 9, Plate IX). A high leuko- 
cytosis would be confirmatory. From erysipelas scarlatina can be 
distinguished by the shining, glazed appearance and characteristic 
spreading. 

The Fourth or Duke's disease is of interest in this connection 
because of its confusion with scarlet fever, provided we accept the 
dictum that attacks of the Fourth disease do not protect the individual 
against scarlet fever and measles. The disease is described as differ- 
ing from scarlet fever in its longer incubation period, absence of 



262 DISEASES OF CHILDREN. 

prodromal symptoms, such as vomiting, high pulse rate, and severe 
angina. The rash itself shows but little difference except that it usu- 
ally begins on the face and is not extensive. The desquamation, how- 
ever, is profuse and out of all proportion to the exanthem. Renal com- 
plications do not occur. 

As the practitioner is often called upon to offer a diagnosis at 
different stages of the disease, the distinctly helpful phenomena to be 
observed at various stages in scarlatina will be given. 

Preeruptive Stage. — Here the diagnosis is only rarely possible 
and then it can be made only in the presence of an epidemic and a 
history of contagion. The sudden invasion with an angina, bright 
red puncta seen in the roof of the mouth, and initial vomiting without 
satisfactory cause, may be symptoms anteceding the eruption. 

Eruptive Stage. — The diagnosis is at this period rarely obscure. 
The vomiting, high pulse rate, characteristic punctate rash, congested 
fauces and evidences of the "raspberry" tongue are usually conclusive, 

Predesquamative Stage. — The rash has faded or disappeared, 
and desquamation has not yet begun. Here the distinctively glazed, 
papillated tongue and the injected fauces are seen. The enlarged 
lymph nodes beneath the maxilla are tender to the touch. The skin 
looks dirty yellow under a glass slide, and has a distinctly dry and 
uneven feel. Sudamina or miliary vesicles may be present in groups. 

Desquamative Stage. — When the disease is seen late, exfoliation 
beginning on the face may be found on the fourth to the sixth day 
of the disease, and on the neck and chest about the twelfth to the 
fourteenth day. On the palms of the hand and soles of the feet it per- 
sists sometimes for weeks; this possibly serving to differentiate it 
from the scarlatiniform erythemas. "Pin-hole" scaling on the body 
and the lines on and beneath the finger-nails strengthen the diagnosis. 
It is not uncommon to find still further corroborative evidence at this 
stage in complications of the kidneys, joints, in the ear or in suppur- 
ating cervical glands. 

Prognosis. — In the mild cases this is extremely good. The septic 
cases in the epidemics raise the mortality. In this country the 
mortality in several epidemics averaged 3 per cent. Nephritis is the 
most common complication and often a fatal one through uremia. 
The chronic form reacts badly to treatment and often ends in death. 
Otitis and its complications may result in deaf-mutism or have a 
fatal issue through the involvement of the brain or sinuses. The in- 
volvement of the serous membranes of the heart or joints tends to a 
grave prognosis. The older the patient the better the prognosis. 



THE EXANTHEMATA. 263 

Treatment. Prophylactic. — The routine examination of school 
children which is now practised in a number of the largest cities, will 
notably tend to diminish the number of scarlet fever cases and pre- 
vent epidemics. Isolation should be insisted upon, and be carefully 
carried out even in mild or suspected cases. Children or even adults 
who have been subject to pharyngitis or tonsillitis are more hkely to 
take or spread the infection. Air and sunlight should be regarded as 
the best disinfectants. 

Children from whom enlarged tonsils and adenoids have been 
previously removed are less liable to such complications as otitis and 
sinusitis. 

Sick-room and Quarantine. — A quiet sunny room that can best be 
used for purposes of isolation should be selected. An open fire-place 
is preferable to any other form of heating. 

All unnecessary furniture should be removed, a gown or sheet 
and a bowl of bichlorid of mercury(l-lOOO) should be placed in readi- 
ness in an empty closet outside of the room for the use of the doctor. 

During convalescence toys of little value, that can be burned, 
should be provided so that the period of quarantine which is usually 
six weeks may not be too irksome for the child. 

Disinfection can be carried out as described on page 312 when 
the patient is ready to be discharged. 

Routine Measures. — All cases of scarlet fever, whether mild or 
severe, should be regarded as dangerous, as the complications and se- 
quelae may permanently inj ure the patient. Skilled nursing will do more 
to promote the comfort, progress, and the prevention of complications 
than remedial measures. If circumstances will not permit of a 
trained nurse, some one member of the household should be put in 
charge and given careful instructions as to the quarantine regulations 
and written orders for the patient. 

The diet should consist wholly of milk in the first few days of the 
illness, later for the sake of variety fruit juices, whey, buttermilk, or 
matzoon may be added or substituted. 

When convalescence is established, gruels, crackers, well-toasted 
bread, and apple sauce may be added to the dietary. Vegetables 
and eggs are allowed in the fourth or fifth w^eek if there is no fever or 
other contraindication. Water should be offered often and freely 
throughout, the illness. 

The skin should be annointed with a 5 per cent, boric acid oint- 
ment or with liquid albolin daily as soon as desquamation is estab- 
lished. If the pruritis is troublesome a 1 or 2 per cent, carbolic acid 
ointment will be effective in its control. 



264 DISEASES OF CHILDREN. 

The nasopharyngeal toilet should be made daily with a mild alka- 
line antiseptic or a normal saline solution. The method employed will 
depend upon the age of the child. Those who are old enough and 
willing may gargle. A spray or irrigation is necessary for the ob- 
streperous or septic cases. The solution may be instilled with a medi- 
cine dropper into the nares of infants. 

The Urine. — A specimen should be obtained for examination 
(see Methods, page 445) three times a week. If this is done the com- 
plicating nephritis will be detected ear y and proper measures can be 
taken at once. 

Symptomatic Treatment. — The fever, if high, above 104° F., can be 
controlled by sponging with water 85° to 90° F. every two or three 
hours. Cool packs are rarely necessary except in those cases in which 
there is considerable restlessness and delirium. The child may then 
be wrapped in a sheet as described on page 84 and left in this for a 
few hours if sleep is produced. 

Heart. — ^Persistent high fever, especially in the septic cases, may 
weaken the action of the heart so that the pulse becomes soft and 
somewhat irregular. The first sound is not distinct and the pulse rate 
becomes high. Stimulation with strychnia alternating with the tinc- 
ture of strophanthus is now indicated. Alcohol in the form of sherry 
wine (vini xerici) may be substituted profitably in the septic cases. 
One to two ounces may be given diluted in water or milk during 
the twenty-four hours to a five-year-old child. Normal salt solution, 
two to three ounces, given by hypodermoclysis may tide over a criti- 
cal period. 

The bowels are kept open preferably with the effervescent citrate 
of magnesia. Constipation which is so often present on a strictly 
milk diet will not be so troublesome if the dietary is varied as out- 
lined above. The milk of magnesia may be added to the bottle in 
infants. 

Complications and Sequelae. — The cervical adenitis which so 
often occurs requires the use of ice-bags in the early stages. Ichthyol 
ointment 20 to 30 per cent, in lanolin is applied daily when the acute 
symptoms have subsided. The abscess must be incised and drained 
if fluctuation denoting suppuration is detected. 

Nephritis will necessitate the continuance of a liquid diet, alkaline 
diuretics, and in the graver cases high colonic irrigations of saline 
solution twice a day until the normal amount of urine is reached. 

Otitis. — The ear drums should be examined every other day as a 
routine measure, and any redness and bulging should receive prompt 
treatment by incision and drainage as outlined on page 591. If 



THE EXANTHEMATA. 



265 



this is done, chronic otitis and mastoid infections with their sequelae 
may be avoided. 

Arthritis occasionally occurs as a complication which prolongs the 
convalescence, and if neglected may cause joint deformities (Fig. 68). 
Aluminum acetate solution, N.F., applied as a wet dressing, with small 
doses of phenacetin, may arrest the infiammatian and control the 
pain. If suppuration takes place surgical intervention is necessary. 
At the Willard Parker Hospital good results have sometimes been 
obtained by immobilizing the inflamed joints with plaster of Paris. 




Fig. 70. — Arthritis, following scarlet-fever, in left hip-joint. 



The Serum Treatment. — Except in those cases which by culture 
give evidences of an added Klebs-Loeffler infection, serum therapy as 
thus far elaborated is without value. Diphtheria antitoxin then 
should be administered in those cases only in which a true diphtheria 
is present. 

Small -pox. 

(Vainola). 
Definition. — Small-pox is an acute contagious disease characterized 
by a period of incubation, a prodromal stage with intense constitu- 
tional symptoms, followed by a progressive eruption of macules, pap- 
ules, vesicles, pustules, and cicatrices. 



266 DISEASES OF CHILDREN, 

Etiology. — Specific. — Councilman in 1903 discovered a protozoan 
in the skin of small-pox patients. The relation of these parasites to 
the skin lesions is of such a definite and intimate character as to lead 
to the conclusion that they are the cause of the disease. They have a 
double life cycle, intracellular and intranuclear, which they undergo 
in the epithelial cells. In the first cycle they are small homogeneous 
bodies found in vacuoles in the cells of the lower layer of epithelium, 
and develop there into large ameboid multi-chambered organisms, 
destroying the epithelial cell and by segmentation breaking up to 
form the protozoa of the second cycle. These invade the nuclei of 
other epithelial cells and continue their growth until the cell is de 
stroyed. The parasite has not been found free in the vesicle contents, 
nor anywhere, as yet, except in prepared sections of the skin. 

Non-specific. — The contagium exists in the secretions and excre- 
tions, in the skin lesions, and in the dried scales and crusts that come 
from them. It clings to everything with which it comes in contact, 
and may therefore be transmitted by a third person; all public places 
are thus dangerous for an unvaccinated individual during an epidemic. 
It is probably contagious during the prodromal stage as well as through- 
out the course of the eruption an desiccation. A very virulent case of 
variola may be contracted from the mildest varioloid. Vaccination 
protects for a variable time (six years to a lifetime) in different individ- 
uals, and always lessens the danger and severity of an attack. One 
attack protects for life. 

Pathology. — The papule is seen to be a focus of coagulation ne- 
crosis in the rete mucosa, surrounded by an area of active inflamma- 
tion. The vesicle is made up of numerous recticula; and spaces which 
contain serum, leukocytes, and fibrin. When the pustule involves the 
true skin a permanent scar results. 

Incubation. — Twelve to fifteen days. 

Prodromal Stage. — Three or four days. 

Symptomatology. Description of Prodromal Stage. — This is 
ushered in with convulsions, vomiting or a chill, and in older children 
severe frontal headache and backache are complained of. The tem- 
perature quickly rises from 103° F. often to 106° F. The pulse becomes 
rapid and full, and within twenty-four hours there may be delirium 
and marked restlessness. This condition continues with no di- 
agnostic signs on the skin usually for four days, when the eruption 
appears. Simultaneously there is a fall of temperature even to 
normal in the less severe cases, and marked improvement in the 
general symptoms. 

The Exanthem. — At first the exanthem is in the form of small 



PLATE X. 




Differential diagnosis of variola and varicella, (a) variola; (6) varicella. 



THE EX.\XTHEAL\TA. 267 

raised red papules, most commonly developing on the forehead, 
particularly at the junction with the hair, and on the wrists. They 
rapidly extend to the rest of the face and to the extremities, in- 
cluding the palms and soles, and in less numbers to the trunk. 
They all come out in one crop within twenty-four hours. They 
feel hard and have the so-called '^shotty'' touch, because they 
extend deeper into the skin than other papules, as, for instance, those 
of chicken-pox. These same red papules are to be seen on the hard 
and soft palate and pharynx causing an accompanying sore throat. 
In two days, sometimes less, the papules on the skin become vesicular 
with a slight depression in the center of each vesicle, and if pricked 
with a needle they do not collapse because they are divided into many 
parts by a reticular construction. They still have an indurated red- 
dened base. On the eighth day of the disease, four days after their 
first appearance, the vesicles become full and rounded and the serum 
in them changes to pus. The skin becomes tense and swollen, and 
the individual lesions enlarge, so that in the severe cases (confluent 
form) they coalesce and the face appears much swollen and changed 
beyond recognition. This is accompanied by a second rise of tem- 
perature (secondary fever), and a return of the constitutional symp- 
toms with redoubled vigor. \ The delirium returns, the pulse grows 
weaker, and the patient shows every sign of a severe intoxication. ^ In 
the fatal cases this may go on for two or three days with increased 
severity until death results. But in the milder cases, within twenty- 
four to thirty-six hours after maturation takes place, the pustules 
break and the pus exudes, and on the tenth or eleventh day the tem- 
perature begins to fall by lysis. The pustules rapidly dry with the 
formation of crusts, and usually during the third week the temperature 
becomes normal and the desiccated pustules alone remain. These 
may adhere for a week or longer until at last they fall off and leave the 
scar or pit which may. especially in the confluent form, be carried 
throughout life. A leukocytosis occurs in the pustular stage, but at 
no other time unless there is some complication to cause it. 

Variations, Complications, and Sequelse. — There are really four 
forms of small-pox, differing chiefly as to their severity; varioloid, 
discrete, confluent, and hemorrhagic small-pox. Varioloid is a pox 
modified by a previous vaccination, and does not often occur in chil- 
dren, since a child that has been successfully vaccinated is generally 
immune until after puberty. The mild discrete form is also unusual, 
because in unvaccinated children small-pox is apt to run a very severe 
course. These two forms are mild and differ only in degree. The 
symptoms are all milder than in the other two forms, although the 



268 DISEASES OF CHILDREN. 

initial temperature may be high. The papules are fewer in number, 
particularly on the face, and do not coalesce. The disfiguration is 
less. There is less secondary fever from suppuration (in varioloid 
often more) and convalescence is there ore much more rapid. In the 
confluent form the eruption is apt to appear earlier, about the third 
day, with a lesser fall of temperature upon the advent of the eruption. 
There is more swelling and distortion of the features during the suppu- 
rating and coalescing stage and more pain. Delirium, ceaseless, rest- 
less movements, and other nervous manifestations are prominent in 
children. Diarrhea is also peculiar in children. The larynx and 
pharynx may be greatly swollen. Edema at times being the cause 
of death through suffocation. The cervical glands are much swollen 
and may suppurate. Hemorrhagic small-pox may show itself either 
before the real eruption appears or at the time of suppuration and 
secondary fever; the earlier the hemorrhage, the greater the danger. 
At first there are small punctiform hemorrhages. They rapidly in- 
crease in size, and soon hemorrhages appear from the mucous mem- 
branes, hematemesis, hemoptysis, epistaxis, and hematuria develop. 
Large conjunctival hem^orrhages with deepty sunken cornea complete 
the picture. The pulse is rapid and the respirations frequent. On 
the other hand, hemorrhage into the vesicles themselves with abortion 
of the rash and speedy recovery even in cases that were previously con- 
sidered severe, have been noted. 

Other complications are fatal; edema or necrosis of the larynx. 
Bronchopneumonia is common. Heart and kidney complications 
are rare. Arthritis going on to suppuration, and acute necrosis of 
the bones have occurred. The eye may be permanently injured by 
inflammatory changes. Otitis media may complicate. Boils, acne, 
and ecthyma are apt to be troublesome sequelae. 

Prognosis. — The matter of previous successful vaccination is the 
most important item in the course and termination of small-pox. 

In one large epidemic the mortality of the unvaccinated was 54 
per cent., while that of the vaccinated was i- of 1 per cent. In chil- 
dren it is particularly fatal. Of 3,164 deaths in the great Montreal 
epidemic, 85 per cent, of these were in children under ten years. The 
younger the child the more serious the course, and the more fatal the 
outcome. The hemorrhagic form is almost invariably fatal. The more 
numerous the lesions on the face the more grave is the prognosis, as is 
seen in the high mortality of the confluent form. High fever, delirium, 
continued, convulsions and other nervous symptoms are particularly 
dangerous. Laryngeal and pulmonary complications are very fatal in 
children. 



THE EXANTHEaiATA. 269 

Prophylaxis. — Vaccination is the measure which, if thoroughly 
carried out, would eradicate this disease. 

The strictest quarantine regulations must be enforced even in 
suspected cases; all individuals exposed are to be immediately vacci- 
nated. The demands of school boards that all children be frequently 
vaccinated has been followed by the most satisfactory results. 

Treatment. — If the patient has not been vaccinated, and is in the 
incubat'on stage, the ravages of the disease may be prevented and 
only a mild course observed, if he be immediately vaccinated. The 
high fever is controlled by cold sponging and the use of the ice-bag 
under skilled supervision. The racking pains are best controlled in 
children by Dover's powders. Water is freely demanded and should 
be freely given. Convulsions and other nervous phenomena may be 
prevented and relieved by insisting upon a cool temperature in the 
room; preferably at 65° to 70° F. The diet should be hquid during 
the febrile period. A 4 per cent, solution of boracic acid should be 
used for the eyes, mouth, and nose. A 2 to 5 per cent, ichthyol 
ointment, or a wet dressing of the liq. alumini acetatis (N.F.) will 
very effectively control the itching in the eruptive stage. A great 
deal may be done for the patient during the stage of suppuration. 
Welch, who has had a large experience, recommends the application of 
a mixture of olive oil and lime-water ^ oz. each with carbolic acid ten 
to fifteen drops. Elbow sleeves will effectively prevent the child from 
scratching and thus causing j^itting and disfigurement. Martin states 
that he can prevent pitting by treating each pustule by incision and 
drainage. The patient's strength is to be carefully watched and strych- 
nin prescribed at the first signs of a weakening heart. In the con- 
valescent stage, forced feeding will serve as the best tonic treatment. 

Vaccination. 

Definition, — Vaccination is the innoculation of an individual with 
the virus taken from the vesicle of a cow that has vaccinia or cow-pox. 

Etiology. — It is now known that vaccinia is caused by a proto- 
zoan which resembles that of small-pox, but which differs from the 
latter in that it has only one life cycle, the intracellular form described 
under the etiology of Small-pox. 

Value of Vaccination. — In the immense majority of cases vaccina- 
tion renders the individual immune from small-pox for many years. 
Before it was generally practised terribly fatal epidemics swept over 
different parts of the world, carrying away enormous numbers of 
victims. Rotch states that in the last fifteen years no deaths from 



270 DISEASES OF CHILDREN. 

small-pox have occured in Boston in children who had been vaccinated 
under five years of age, and at the same time the mortality in the un- 
vaccinated was 75 per cent. Where small-pox is acquired after suc- 
cessful vaccination, even years after, it is the mild form, called varioloid. 

When to Vaccinate. — Every infant should be vaccinated prefer- 
ably between the fourth and sixth months of life, before teething has 
begun and before the child can disturb the dressing. An acute or a 
severe chronic disease is a contraindication except in an emergency. 
Revaccination is advisable at puberty, and at any other time when 
the child has been exposed to small-pox or during a general epidemic. 
If an unprotected child is vaccinated within two days after exposure 
to small-pox, it will probably not contract that disease, and if vacci- 
nated within five days thereafter the small-pox will be modified, and 
it will convert a possibly severe case into a mild one. 

Method of Vaccination. — Only sealed tubes or quills should be 
used. Boys are vaccinated on the left arm at the insertion of the 
deltoid, girls on the thigh or calf. The skin is carefully cleaned with 
soap and water and a piece of sterile gauze. It is then washed with 
alcohol and allowed to dry. A large sewing-needle is sterilized by 
heating to a red heat over a lamp or a lighted match. The skin is 
pulled taut without touching the place to be vaccinated and lightly 
scarified criss-cross without bleeding, in two places J inch apart, each 
being | inch square; the vaccine is then unsealed, applied and gently 
rubbed in. It is next allowed to dry for twenty minutes, care being 
taken that it is not contaminated at this time. When dry a piece of 
sterile cotton or gauze is laid over it and firmly fastened with strips of 
adhesive plaster. Vaccination shields should not be used, as much 
contaminating dust and dirt may collect under them. The dressing 
should not be disturbed except by the physician for the purpose of 
seeing if the vaccination is successful and uncomplicated at the end 
of the week. It should be very secure in children who are old enough 
to tear it off. Vaccination should be attempted at least three times 
with a different lot of virus each time before one should say that the 
child cannot be successfully vaccinated. 

Description of Normal Course. — The scarified area appears to be 
healing with no general symptoms until the third to fifth day, when a 
small papule develops at the sight of inoculation. This increases in size, 
and after one or two days develops into a large vesicle with a raised 
margin and depressed center, the whole surrounded by a red areola. 
By the eighth day it has attained its maximum, and on the tenth day 
the contents are purulent. The surrounding areola is extensive, swol- 
len, indurated, and painful. The axillary or inguinal glands, according 



THE EXAXTHE^LITA. 271 

to the site of vaccination, are large and tender. On the eleventh or 
twelfth day the hyperemia diminishes and the pustule begins to dry 
up, and by the end of the second week only a brown crust remains; 
this comes off in another week, leaving a round, pitted scar. Usually 
on the fourth or fifth day some fever and more or less marked consti- 
tutional symptoms develop and last three or four days. The vaccina- 
tion has not been successful unless, 1. some reddened areola surrounds 
a typical vesicle; 2. there is some swelling of the h^mph-glands; 
3. some, even slight, fever and constitutional symptoms; 4. there 
should be a permanent scar in which even years after, numerous small 
pin-point-sized depressions are seen. This last characteristic is very 
valuable in determining the success of a vaccination for a number of 
years after. 

Variations and Complications. — The vesicle may abort and dry up 
in seven or eight days, in which case revaccination should be practised. 
Generalized vaccina at times shows itself at the end of the first week 
by a vesicular eruption in any part of the body. It may continue to 
make its appearance for five or six weeks. It is not serious, as a rule, 
but has been known to be fatal. Recurrences of the vesicle at the 
site of the original vaccination are rare. Reinoculation occurs in 
children who have scratched the original vesicle and then vaccinated 
themselves in different parts of the body. 

Infection with other organisms results from 1. contaminated 
virus; 2. lack of asepsis in vaccination; 3. traumatism and contami- 
nation during the vesicular stage. If the vesicle is not ruptured it is 
not liable to be contaminated, but with a sterile dressing over it 
there is double protection. The results of contamination may be 
ulceration more or less severe, or even an extensive necrosis; suppura- 
tion of the lymph nodes; septicemia or suppuration in the joints. 
Tetanus, syphilis, and tuberculosis are almost never seen now that 
animal lymph is used. Other complications are eczema, general urti- 
carial or scarlatiniform erythematous eruptions. These may occur 
from the first to the fifth weeks. 

Varicella. 

(Chicken-pox.) 

Definition. — Varicella is a short, mild, contagious disease, with a 
long period of incubation, a short prodromal stage, followed by an 
eruption of superficial papules going on to vesiculation. 

Etiology. — No specific microorganism has yet been discovered. 
It is an independent disease not closely allied to small-pox. It does 



272 DISEASES OF CHILDREN. 

not protect from small-pox, nor does small-pox protect from it. The 
disease is most common between the ages of two and six years, and 
is rare after puberty. It is communicable on slight, short contact, 
the mode of entrance not being known. 

Pathology. — The papule and vesicle is near the surface, being 
formed by the upper layer of the epidermis. The vesicle is seldom 
multilocular, and unless deeper ulceration takes place, which occasion- 
ally occurs, it does not leave a scar. 

Incubation. — Ten to eighteen days, usually fourteen days.* 

The prodromal stage lasts about twenty-four hours. 

Description. — After a day of slight malaise, with perhaps a tem- 
perature of 101° F. to 102° F., a few red papules, varying from pin-head 
to pea-size, are seen anywhere on the body. Usually they are few 
in number and scattered over the face, trunk, and extremities. The 
temperature may be lowered a degree or more after the eruption comes 
out, but the patient still has some constitutional symptoms. A slight 
sore throat is the rule, as a few of the same isolated red papules appear 
on the fauces and pharynx. Within a few hours vesicles take the 
place of the papules which first make their appearance, and at the 
same time another crop of papules appears scattered here and there, 
between them. This process continues three or four days, so that 
at any one time the lesions in their various stages may be seen as small 
and large papules, beginning vesicles, large full rounded vesicles, and 
those that are drying up. They may be an inch or two apart, or 
they may be much closer together. They usually have no umbilica- 
tion, feel soft to the touch, and collapse when pricked with a needle. 
As a rule, they do not go on to pus formation, but contain a clear, or 
at most, a slightly turbid fluid. After two or four days they dry up, 
the temperature is normal, and convalescence is established. 

Variations, Complications, and Sequelae. — Many children show 
little or no constitutional symptoms. Rarely there may be a high 
fever, even to 105° F., and corresponding symptoms, but this is the ex- 
ception. In some cases the eruption is profuse on the vulva and nates, 
with consequent vesical and rectal tenesmus. Occasionally one or 
two of the vesicles become infected and more or less deep destruction 
of tissue results. Cases of high fever and pustulation of all the vesicles, 
lasting a week or longer, have been reported. A depression in the 
center of each vesicle, that is, umbilication, is not typical, but it occurs 
often enough to be misleading in differentiating an atypical case from 
small-pox. 

Albumin in the urine is not uncommon, but true nephritis is rarely 
seen, except in an unusually severe case. Acute simple inflammatory 



X 






o 






a 


M 




rt 


>, 




o 


a 




^ 


-o 




o 


•^ 


"^ 


-C3 


7—1 


:3 


O 


o 


o 






'-"' 




o 


•* 






(M 



1^ a 



p '^ ^ Cr:;^ 

•— vr ?1 ^ ^-^ C3 CC 

02 C rt O C^ > O- '^- 



' — ^ M M M c o ^ ,; 

g S 2 1^ c| I 









c5 C! 



O 

or, rt 



^ rt s o ^ 

O C :3 O 5 
02 C K ^ C 



O 



X 

o 

02 






curt 



O 



^:s a o 

O 02 O 



zn 



^ c •_::; M X '■'^ ^ 



C o o F' 



•ir; o 

^ !- f- O O 



^ O 50 t- O Q 

^ rt ^ c S^ 



"1 

I'll 

.If £1: 



?2 O >j 



r P 2 



02 OS 

■So 






faJO 



-T3 O 



r^ X' 13 • -I . — I 
" cj > M ZJ 

—st: Jh X -^ 



■^ — CI 






^ 3 
biS 



':3 

X ^ 
C- c3 > 



p=^ 



ip 






02 f*! 






P-S 












13 
o 


^^ 


^ 


-^(M 


<n 


^ >. 


CO 
















Ttl 


(M 


(M 






a 


i 
1 






bn 






rt 












X 


CI 




O 


«i 


+3 


Fi 


rt 


o 


X5 


;: 




T3 


o 


o 


c 




- 





• :4 o :3 o~ ::: 

G G c3 'r^ C3 5;£ 
S S'— O ^ G 

all ° o 13 -^ 

'^•ai':^ xfH3 

^^S X 5 S 



Si 



i8 



^ X I X 

^ S £ d 
■> So. 2 

^ s^ > 

o S i: .9 

X '^ ^-^ 



o a 






•d ^ & 



X f^ ,H 

-ij d 

X o 

X - <u . 

&.— o o 5 



^£d 



o 






274 DISEASES OF CHILDREN. 

involvement of the joints, lasting only a few days, has been noted. 
Otitis and pneumonia are rare complications. 

Prognosis. — Recovery to is be expected after a short mild illness. 

Treatment. — To prevent the transmission of the disease, isolation 
from other children should be insisted upon, for although the disease 
is mild it occasionally produces some serious consequences. The child 
should be kept from scratching the vesicles to prevent infection by the 
finger-nails. An initial dose of 1 gr. of calomel, and a liquid diet are 
the only measures, as a rule, required during the illness. 



Diphtheria. 

Diphtheria is an acute infectious disease due to the growth and ac- 
tion of the Klebs-Loeffler bacillus on a vulnerable surface producing 
a local membrane and general toxic symptoms. 

Etiology. — The disease is endemic in large cities. Local epidemics 
frequently occur in small towns and villages. Statistics show the 
disease to be more prevalent in the winter and fall than in the summer 
months. In fact, vacation periods show a falling off in all infectious 
and contagious diseases. The disease is contracted directly or indirectly 
from another case of diphtheria. The indirect means are usually 
the handling of infected objects and attendants who do not take proper 
precautions. Even contaminated food, such as berries and milk, have 
been known to infect the consumer. There is no discrimination as 
to sex; age, however, plays an important part. Nurslings possess con- 
siderable immunity. The third to fifth year is the period of greatest 
liability. From the tenth year to puberty, the susceptibility markedly 
decreases. Children of the so-called 'lymphatic diathesis" are par- 
ticularly vulnerable, as are those who have been weakened by pre- 
vious' diseases. 

Pathology. — The pathology is in the main that of the pseudomem- 
brane. This is a true coagulation necrosis, wich may be situated upon 
the pharynx, nasopharynx, larynx, or trachea. More rarely it is 
found upon the mucous membrane of the nose, conjunctiva, or vaginal 
membrane. The bacillus or its toxins circulating in the blood may 
produce myocardial changes of a fatty or degenerative nature. The 
cervical lymph nodes show a simple cell hyperplasia. The involve- 
ments of the lungs and kidneys must be regarded as complications. 

Symptomatology, — The symptoms differ as they are the results 
of a pure or a mixed infection, and as to the anatomical distribution 
of the pseudomembrane. The mixed type is usually an association of 
the Klebs-Loeffler bacillus with the streptococcus as in scarlatina. 



PLATE XI. 







Differential diagnosis of (a) follicular tonsillitis; (6) scarlatinal angina; 
(c) diphtheria; (d) lacunar tonsillitis. 



THE INFECTIOUS DISEASES. 2/5 

The general symptoms of any of the forms of diphtheria are 
dependent upon the degree of toxemia. The attack is usually ushered 
in with vomiting or a chill. There is no characteristic temperature 
curve. The fever is of a low grade, 101° to 102° F., in uncomphcated 
cases. The pulse rate is increased in direct proportion to the youth- 
fulness of the patient. Lassitude or somnolence in various degrees 
may be observed before local lesions are suspected. The quantity 
of urine is diminished, and traces of albumin are found in a large 
proportion of the cases. The blood shows a hyperleukocytosis, 
especially in the polynuclear elements. The red blood-cells and the 
hemoglobin are correspondingly diminished. 

Diphtheria (Tonsillar and Pharyngeal). — In this type the clinical 
manifestations vary from those of an extremely mild variety to 
severe toxic cases. The child may not complain of any sore throat 
and the membrane may be found only on routine examination. On 
the other hand, there may be low fever, vomiting, and some difficulty 
in swallowing. Examination of the throat, which should always be 
done with the best possible light and with a curved tongue depressor, 
may show membrane in the form of a grayish-white patch on one or 
both tonsils. The tonsils may be enlarged and congested. The 
uvula or adjacent pharynx soon become involved (see Plate XI). 
A grayer or dirtier colored membrane is seen after the third or fourth 
day. In severer cases the uvula, posterior pharynx, and fauces show 
the characteristic membrane. The general symptoms are now more 
aggravated, due to the toxemia; prostration is marked. The glands 
of the neck enlarge and become painful. There is dysphagia and 
difficulty in enunication. There may be delirium. The breath is 
offensive and quite characteristic. The pulse is rapid and feeble. 
The temperature is irregular and at times high. If in this form we 
have the added complication of a mixed infection the toxemic symp- 
toms are still further aggravated, becoming those of a true sepsis. 
Complications are then apt to supervene early, and the kidneys 
almost invariably suffer. 

Differential Diagnosis. — Tonsillar diphtheria must often be dis- 
tinguished from a follicular tonsillitis, especially if the exudation 
from the crypts has merged, and seemingly forms a membrane. This 
is especially necessary in the absence of a bacteriological diagnosis. 
(Plate XI.) 

In follicular tonsillitis, both tonsils are usually involved simul- 
taneously. There is an initial high temperature of 104° to 105° F. 
Usualh^ there is no vomiting. Careful inspection will reveal isolated 
cry{)ts distended with their cheesy detritus. The pseudomembrane 



276 DISEASES OF CHILDREN. 

can be readily removed. The diphtheritic membrane, on the other 
hand, adheres closely and leaves an excoriated and bleeding surface 
if forcible attempts are made to remove it. The bacteriological 
diagnosis should be made whenever feasible, but the returns should 
not be waited for except in extremely mild suspicious cases. The 
bacteriological examination may be made with a smear prepara- 
tion stained with Loeffler's solution and directly examined, or by 
inoculating the tube of blood serum and examining the growth after 
twenty-four hours of incubation. The precaution should be observed 
to take the culture before any antiseptics have been applied, or at 
least within some hours thereafter. 

Laryngeal Diphtheria. — In this form the membrane may extend 
from the nose or throat, or it may primarily involve the larynx. 
In the latter case there are symptoms due to congestion of the mucous 
membrane of the larynx and the vocal cords; that is, a hoarse 
inspiratory cough, some restlessness and a low grade of temperature. 
Cultures, if taken at this stage, are usually found to be negative, 
especially if a laryngeal swab is not correctly used. As the disease 
progresses symptoms of obstruction are apparent*, due to the forma- 
tion of the laryngeal membrane which is sometimes visible about 
the epiglottis. The cough is more aggravated and paroxysmal in 
character; the patient acts as if attempting to dislodge an irritating 
foreign body. There is partial or complete aphonia with a muffled 
or suppressed cough and whispering voice. The accessory muscles 
of respiration are brought into requisition. The periods of remission 
from coughing become shorter and shorter in duration, and are easily 
brought on by disturbing the patient. If the child falls into a restless 
sleep, the symptoms are less noticeable, but do not in any sense 
resemble the normal. 

The pause between inspiration and expiration is noticeably 
prolonged. The supraclavicular, epigastric, and diaphragmatic spaces 
show marked recession at the height of inspiration. The mucous 
membranes and nails are cyanosed. Unless relief is now obtained, 
extreme restlessness sets in, and the child attempts in every way 
to get air; it is markedly cyanosed, a cold perspiration appears on 
the forehead, stupor supervenes with spasmodic breathing, apnea, and 
death. 

In certain cases the membrane may extend to the trachea, even 
beyond the bifurcation of the bronchial tube (see Fig. 71). 

Differential Diagnosis. — We have abandoned the term croup as 
applied to diphtheria as it only tends to misleading conceptions, and 
perhaps to serious mistakes in management. Clinically, the diagnosis 



THE INFECTIOUS DISEASES. 



277 



should be based upon the character of the cough, the aphonia, the 
muffled cry, the progressive signs of laryngeal obstruction, and the 
recession of the thoracic spaces. In non-diphtheritic laryngitis the 
child is taken suddenly ill at night with an attack of suffocation and a 
brassy, barking cough. Ordinary remedial measures, such as steam 
inhalations and emetics, give speedy relief, with the resumption of 




Fig. 71. — Cast of the trachea and bronchi expelled from a case 
of laryngeal diphtheria. 



normal breathing and apparent health during the next twelve to 
twenty-four hours, when a second milder attack may supervene. 
Edema of the lungs, especially when it earl}^ complicates a broncho- 
pneumonia, ma}!^ simulate an attack of laryngeal diphtheria. The 
phj^sical signs must be depended upon to clear up the diagnosis. 

Nasal Diphtheria. — This form is usually seen in children of the 
school age, and unfortunately the cases are not recognized and isolated 
as early as they should be. Children with nasal diphtheria are 
undoubtedly great carriers and disseminators of the infection. The 



278 DISEASES OF CHILDREN. 

disease should be suspected in cases of intractable or aggravated 
rhinitis m which there is a mucopurulent, blood-tinged discharge, 
accompanied by evidences of nasal obstruction. The nostrils and 
upper lip are often excoriated. The children are not sick enough to 
want to go to bed and may have little or no fever. The use of the 
nasal speculum will often show the membrane in the nares. It is 
usually in shreddy patches rather than in firm membranous masses. 
The glands at the angle of the jaw are moderately enlarged. A 
culture should be made in all suspicious cases. 

If the posterior nares is involved by extension from the pharynx, 
the prognosis is graver, as it tends to lessen the respiratory ability 
and the willingness of the child to take food. The toxemia is likewise 
greater, and the cardiac muscle soon weakens. 

Conjunctival Diphtheria. — As in the other forms, this may be 
primary or secondary to the disease of the nose or throat. The 
course is extremely rapid. There may be a profuse purulent discharge 
with marked edema of the eye-lid; the conjunctiva is clouded with a 
thin membrane of a gray color which adheres closely and bleeds easily 
if attempts at removal are made. 

These local symptoms are accompanied by an increase in the tem- 
perature and pulse rate and by somnolence due to the toxemia. 

Complications. — The respiratory tract, the nervous system and 
the heart are the greatest sufferers from the toxemia of diphtheria. 
Pneumonia is a frequent complication, especially in badly nourished 
children or in those that have been intubated. The mixed infections 
predispose to this complication, especially in those under two years 
of age. Postdiphtheritic paralysis occurs in about one-fifth to one- 
seventh of all cases. The common form is the local paralysis of the 
palatal group of muscles; it may come on early or late in convalescence. 
The symptoms are regurgitation of liquids through the nose, dysphagia, 
and dysarthria. The uvula is found relaxed and not supported by its 
muscles. In the severer forms the physiological action of the pharynx 
and larynx is disturbed. The muscles of the lower extremities and the 
eye may be involved in the paralysis. The patellar reflexes are lost, 
and there may be anesthesia of the lower extremities. Only rarely is 
there paralysis of the upper extremity as a part of the general paralysis. 
If the branches of the vagus are involved cardiac irregularity is noticed, 
and vomiting and pains in the abdomen are complained of by older 
children. There is a tendency to sudden death in these cases. Neph- 
ritis occurs as a result of the toxemia and as it often appears insidi- 
ously without puffiness or anasarca, the urine should be carefully 
watched. 



THE INFECTIOUS DISEASES. 279 

Prognosis. — This must be formed by a consideration of the patient's 
age, iiis resistance, the location of the m^^rane, whether of the 
pure or of the mixed type, and the time of the serum administra- 
tion. The following are the mortality statistics from the Boston City 
Hospital. 

(Cases treated with antitoxin.) 

Under five years, 20 per cent, of all cases. 

Five to ten years, 8 per cent, of all cases. 

Ten to fifteen years, 3 per cent of all cases. 

Exclusively nasal cases offer the best prognosis. Uncomplicated 
tonsillar or pharyngeal cases rank next in a good prognosis. Laryn- 
geal cases are the least favorable, especially when the necessity arises 
for intubation or tracheotomy. In private practice, where the cir- 
cumstances are the most favorable, the mortality has been reduced to 
less than one-third of all cases. Antitoxin has been the means of 
reducing all the mortality statistics; and if given before the fourth 
day of the disease the prognosis is very favorably influenced. 

Treatment. — The management may be divided into the prophy- 
lactic, general, serum, local, and operative treatment. 

Prophylactic. — Immunization with antitoxin assumes the first 
place in prophylactic treatment. The immunity lasts from three to 
four Aveeks and, as conclusively proven by the statistics from the New 
York Board of Health and elsewhere, has saved many lives. Thir- 
teen thousand persons received immunizing injections through the 
New York Department of Health; of these only three-tenths of 1 j^er 
cent, had a subsequent mild grade of diphtheria, and there was only 
one death. Immunizing doses of 500 to 1,000 units should be given 
to all the susceptible individuals in a family who have been exposed. 
In hospitals or institxitions patients may be immunized, especially if 
measles are epidemic. All true cases and suspected cases should be 
carefully isolated, and disinfection practised as is indicated in the 
special article on this subject (page 337). 

General Treatment. — The child should be placed in bed in a well 
ventilated, sunlit room, capable of separation from the rest of the house. 
Cool liquid or semisolid foods, such as milk, ice cream, junket, etc., 
should be offered at short intervals. Cold compresses are useful 
to mitigate the dysphagia, while light ice-bladders are often agree- 
able and efficacious when applied to the neck, particularly in glandular 
cases. The bowels should be kept open with calomel or salines. 
The urine should be examined at least bi-weekly. Strychnin sul- 
phate in doses of from ^io- to y-g-o- of a grain, according to the age of 
the child and the necessity for stimulation, may be given every two 



280 DISEASES OF CHILDREN. 

to three hours. Whisky may be alternated with the strychnia in 
toxemic cases with irigj^ular heart action or bradycardia. Small 
doses of morphine 4^ to yg- of a grain are often efficacious in control- 
ling the restlessness, and at the same time acting as a tonic to the heart. 
Infusions of normal saline solution have been of material assistance 
in saving desperate cases. Bromid of sodium if not contraindicated 
by the heart's action is of value as an antispasmodic before extuba- 
tion in laryngeal cases. Paregoric or Dover's powder in small doses 
may be given for the same purpose. 

Serum Treatment. — Antitoxin should be given in all cases of diph- 
theria or those suspected of being diphtheritic. In its improved form 
there are no contraindications to its use. Two thousand units 
should be given in mild cases of faucial or nasal diphtheria, and re- 
peated with a double dose in twenty-four hours if the false membrane 
has not shown signs of disappearing; three to five thousand units may 
be the initial dose in severer cases. In laryngeal diphtheria 5,000 units 
in infants and 10,000 units in older children should be given at once. 
The dose should be repeated in twelve hours in cases of stenosis if 
the respiratory difficulty is not ameliorated. Larger doses must be 
given if the disease is seen in its later stages. Immunization is satis- 
factorily accomplished with injections of 500 to 1,000 units, according 
to the age of the child. 

The loose tissues under the pectoral region or over the right or 
left iliac region may be selected for the site of the injection. The 
skin is made surgically clean, and the antitoxin injected with a large 
sterile syringe and needle. The wound should be sealed with collod- 
ion. The pseudomembrane after the injection of antitoxin slowly 
tends to detach itself. In laryngeal cases, in which the membrane is 
not seen, the decreasing symptoms of obstruction give evidences of 
its good effects. The hypertrophied lymph nodes decrease in size, 
and the general symptoms are all improved. An eruption in the 
form of an erythema or urticaria sometimes follows the injection of 
antitoxin. This is attributable to the horse serum itself. A scarla- 
tiniform or macular rash is occasionally observed. The improved 
concentrated preparations rarely produce skin manifestations. We 
have successfully used the serums prepared by Mulford & Co., Parke 
Davis & Co., and the New York Board of Health. 

Local Treatment. — The curative effect of antitoxin has superseded 
the use of the strong antiseptics which were formerly locally applied 
to the membrane. In older children (those who can gargle) the use 
of a mild antiseptic solution, such as diluted Dobell's solution, listerine, 
or a common salt solution, will assist in removing the loosened mem- 



THE INFECTIOUS DISEASES. 



281 



brane. Younger children are markedly benefited by irrigations of salt 
solution especially in nasal diphtheria (half a dram to the pint) used 
at a temperature between 100"^ F. and 115° F. An ordinary fountain 
bag is used, placed about two feet above the patient's head, who 
lies on his side, prepared as for intubation (see Fig. 72). A 
small nozzle is then placed in one of the patient's nostrils and the 
water allowed to flow for a minute or two, with intermissions to allow 
for expulsion and breathing. If done in this way, the child soon 
becomes accustomed to the process and is not badty frightened, and 
much relief is obtained. In certain cases the nozzle may be inserted 
behind the back teeth, and the mouth thus irrigated. If the bag is 
not placed too high the pressure will not be sufficient to carry infection 
through the Eustachian tube. 




Fig 72, — Position of the patient in intubation. 



An ice-bag applied to the neck in cases of tonsillar diphtheria 
affords relief and tends to inhibit the growth of the membrane, and to 
reduce the swollen lymph nodes. 

Laryngeal cases are often relieved by swabbing away the col- 
lected material at the head of the tube, an ordinary laryngeal appli- 
cator being used for this purpose. Diphtheria affecting the con- 
junctiva must receive as close attention as a case of gonorrheal 
conjunctivitis besides the injection of large doses of antitoxin. 

Intubation. — Intubation or the relief of laryngeal stenosis by the 
insertion of a tube was perfected by Dr. Joseph O'Dwyer, of New 



282 



DISEASES OF CHILDREN. 



York, in 1883. The brilliant results obtained have brought this 
means of rehef into universal favor almost to the exclusion of trache- 
otomy which is now rarely practised. 

The indications for performing intubation are as follows: Intu- 
bation should be performed in laryngeal diphtheria when there is 
marked dyspnea, restlessness, retraction of the epigastric and 
supraclavicular spaces wdth evidences of cyanosis. 

The child is prepared by being closely wrapped and pinned in a 
sheet (Fig. 72). The operation may be performed in a horizontal 




Fig. 73. — O'Dwyer's intubation instruments with detachable parts, 
in an aseptic case. 

position on a table or in an upright position with the child's head 
resting against an assistant's shoulder. A second assistant is required 
to hold the head in the median line and to keep the mouth gag in 
place, as rapidity and a certain amount of dexterity are necessary. 
Practice upon the cadaver, and if possible upon the living subject, 
should be had under the instruction of an experienced operator. The 
instruments used are generally those of the O'Dwyer pattern, as they 
conform most accurately to the anatomy of the region. They are 
now made of hard rubber, metal lined, in sizes according to the age 
of the child. The neck of the tube is held within the vocal cords, 
while its lower end extends almost to the bifurcation of the trachea 



THE INFECTIOUS DISEASES. 



283 



An introducer^ an extubator; the tubes, a mouth gag and scale 
complete the set. 

The proper tube having been selected, a loop is made by threading 
a piece of strong silk through the eyelet placed in one side of its head. 
The child is firmly held by its head and its extremities kept from 
moving by a second assistant when on a table, or bv the knees of the 




Fig. 74. — Introducer, with obturator and tube in place. 



assistant who holds the patient in his lap. The left index-finger is 
inserted and the epiglottis found and firmly held forward. The 
palmar surface of the finger should be presented to the tube. At 
first the handle of the introducer is held parallel to the child's body; 
it is then raised until the tube passes between the vocal cords, when 
it will be beyond a right angle to the body of the child. The trigger 
of the introducer is now used which alloAvs the body of the tube to 
pass well beyond the vocal cords, the finger at the head of the tube 




gently forcing it into place while the obturator is being removed. 
The cord is still kept in place, but the mouth gag should be quickly 
removed. A metallic cough and the relief of the symptoms of stenosis 
will be the proof of success. A series of expulsive efforts followed by 
free inspiratory effort, disappearance of cyanosis, and a period of 
calm and rest for the child will follow. 



284 



DISEASES OF CHILDREN. 




Fig. 76. — Intubation tubes. I, Granulation or built-up tabes; IT, ordinary- 
tube (lateral view); III, ordinary tube (front view). 




Fig. 77. — The forefinger holding the head of the tube in position as the 
obturator is removed. {Northrwp and Nicoll.) 



THE INFECTIOUS DISEASES. 



285 



Failure may result because the operator has not kept closely to 
the dorsum of the tongue in passing his tube, or because he has failed to 
keep the handle of his instrument parallel to the child's body in the 
first movement toward the epiglottis. In rare instances a certain 
amount of membrane is pushed down before the tube, and as a result 
there is no relief, or there may be an increase in the stenotic symptoms. 
The child should then be held in an inverted position, when the 




Fig. 78. — Extubation. 



membrane usually is expelled, and the tube may then be reinserted. 
If any force is used damage may be done. The cord may be removed 
after some minutes by placing the finger on the head of the tube and 
withdrawing it, or it may be fastened on the side of the face with 
adhesive plaster. 

Extubation. — This should be performed as soon as there are 
evidences of marked improvement in the general condition of the 
patient as shown by decreased toxic symptoms, and a marked decrease 
in the laryngeal obstruction. This may occur on the third, fifth, or 



286 DISEASES OF CHILDREN. 

seventh day, depending upon the severity of the case, upon the early 
use of the antitoxin, and upon the age of the child. Children under 
two years of age cannot, as a rule, be extubated as soon as older children. 

If cyanosis follows the removal of the tube, it must be quickly 
replaced, all the preparations having been made for this possibility. 
Special tubes with built-up heads and retention swells are used 
in cases demanding prolonged intubation (Fig. 76). They act by 
preventing and causing destruction of the granulation tissue. 

The Feeding of Intubated Cases. — Older children soon manage to 
take fluids and semifluids without much difficulty. Infants and 
younger children may be fed in a prone position, or with the head 
lower than the body, being fed, if necessary, by a bottle or medicine 
dropper for a few days. Feeding by gavage may occasionally be 
necessary. 

Tracheotomy. 

Indications for Tracheotomy. — Tracheotomy should be performed 
in those cases in which intubation has failed and the membranes are 
forced further down into the larynx. In cases in which the membrane 
forms below the tube and no relief is obtained, and in cases of edema 
of the glottis in which there is extensive infiltration. 

It may here be mentioned that intubation is far preferable to 
tracheotomy, and the latter operation should be performed only as a 
last resort or in those rare cases in which a proper tube is not retained. 

The operation should be performed under a light general anes- 
thetic. The patient should be prepared as for any aseptic operation if 
the circumstances allow, the neck being extended over a sand-bag and 
kept in the median line. An incision one to one and a half inches long 
is made through the subcutaneous tissue, and then the facia and sterno- 
hyoid muscles are separated. The engorged venus plexus is pushed 
to one side and the trachea exposed. By means of a bistoury an 
opening is made sufficiently large to admit the cannula. (An instru- 
ment which will at once incise and dilate the tracheal wound is now 
on the market.) 

When free respiration is established, the cannula is fastened in 
place by tapes about the neck, and the wound dressed with moist gauze. 
A steam atomizer to moisten the respired air is helpful. The attend- 
ant should diligently remove the tracheal secretions deposited upon 
the pledgets of moistened gauze. The inner tube of the cannula should 
be removed and thoroughly cleansed three or four times a day, or 
whenever it is obstructed. After the third or fourth day an attempt 



THE INFECTIOUS DISEASES. 287 

may be made to permanently remove the cannula. If the patient can 
get along without it; the wound is cleansed, dressed, and allowed to heal. 



Pertussis. 

{Whooping-cough.) 

Pertussis is an acute infectious disease characterized by a par- 
oxysmal cough that consists of repeated expirations ending in an in- 
spiratory whoop which is often followed by vomiting. Owing to its 
complications it must be classed as one of the dangerous diseases of 
early life. 

Etiology. — No specific organism has as j^et been found which can 
be said to be the true etiological factor. The secretion is apparently 
the means of transmission from one individual to another and is very 
communicable. Clothing and the rooms of the patient do not seem 
to carry or retain the infective agent. Sporadic cases are constantly 
seen in large centers, and epidemics frequently occur both in urban and 
in rural districts. Whooping-cough is no respecter of age. It has oc- 
curred in the newly-born and in well-advanced adult life. Children 
under two years of age show the greatest susceptibility, while suckhngs 
are in some cases immune. The period of incubation is from seven to 
fourteen days. The primary stage is probably the time of greatest 
danger to others. 

Pathology. — The larynx and trachea show a marked congestion 
and exudative inflammation of their mucous membrane. In fatal 
cases, areas of emphysematous lung are commonly found. Subcon- 
junctival and cerebral hemorrhages have been found. 

Symptomatology. — For purposes of convenience in description, 
the disease may be divided into three stages. Namely, the primary 
(in which the mucous rnembranes of the nose, larynx and trachea are 
inflamed), the spasmodic stage, and the period of recession. These, 
however, merge into each other and are not sharply defined. 

Primary Stage. — The exposed child after a varying period from 
two days to two weeks may have suffused eyes, there may be a rhinitis, 
and a congestion of the pharynx is often seen on examination. The 
child does not feel sick, but coughs severely, especially at night. It 
is described as having a croupy character. After a few days it becomes 
more pronounced at night and more frequent in the day time. Physi- 
cal examination at this time may give no evidences of bronchitis if 
this is suspected. These negative signs are valuable in leading to the 
true diagnosis. An increase in the mononuclear leukocytes is quite 



288 DISEASES OF CHILDREN. 

frequently found at this time. A tongue depressor irritating tKe 
pharynx will sometimes produce the characteristic whoop, and thus 
confirm the diagnosis. A rise of one or two degrees of temperature 
is sometimes observed; especially when there is an accompanying 
bronchitis. 

Spasmodic Stage. — This is so named because of the paroxysmal 
cough or whoop which follows the several expiratory efforts. The 
child realizing the approach of a paroxysm, seeks support from its 
attendant or clings to some article of furniture. There are three or 
four violent expiratory efforts, followed by a period of apnea, and 
then the tremendous inspiratory effort is made which, entering through 
a partially closed glottis, causes the so-called whoop. During this 
effort the eyes have become congested, the face almost cyanosed, mucus 
streams from the nostrils, and a mass of mucopurulent secretion follows 
the whoop. Vomiting occurs if there is any food in the stomach. 
Relief now comes to the exhausted patient, and after a brief period of 
rest, during which there is sweating of the forehead and face, the child 
goes back to its play. These attacks may occur ten or even a hun- 
dred times a day. Naturally, the nutrition soon suffers; the face may 
later become edematous or puffy, masking the malnutrition of the 
body. Severe cases may have subconjunctival hemorrhages or bleed- 
ing from the nose or lungs. The urine may show traces of albumin 
and hyalin casts. Convulsions sometimes follow an exceptionally 
severe paroxysm, especially in infancy. In young infants the spas- 
modic stage begins very soon after the beginning of the attack and the 
*' whoop" may be absent. 

Recession of symptoms is shown by a decrease in the number and 
severity of the paroxysms, ending in a cough which persists for several 
weeks. 

■ Complications. — Bronchopneumonia frequently complicates per- 
tussis, especially in infancy. This is the result of an infective process 
made possible by the abnormal condition of the bronchial tubes and 
the lowered vital resistance. It generally occurs at the end of the par- 
oxysmal stage. Bronchitis and emphysema are complicatidns more 
frequently seen in older children. Tuberculosis not infrequently fol- 
lows in the wake of pertussis. It may be localized (from latent bron- 
chial lymph nodes) or even a general miliary tuberculosis may result. 
Severe attacks of vomiting reduce the general nutrition and predis- 
pose to more important complications. Convulsions result from con- 
gestion of the brain, or from minute capillary hemorrhages which may 
occur during the paroxysm. We have seen hemiplegia due to men- 
ingal apoplexy follow a severe paroxysm. Hemorrhages into the 



THE INFECTIOUS DISEASES. 289 

conjunctiva and hernias in various parts of the body also result from 
the severe strain imposed by the paroxysms. 

Course and Prognosis. — In some cases the disease lasts only a 
week or two, but on the other hand, we have seen it persist beyond 
three months. If complications occur it is more apt to be prolonged. 
The mortality of this disease and its complications is higher than is 
generally appreciated. Infants, especially, are prone to fatal attacks 
of pneumonia, convulsions, and tuberculosis. Among the poor where 
undernourished children are most likely to be found the mortality is 
high. 

The prognosis is based upon the general condition of the child, 
the number, and character of the daily paroxysms, and its ability to 
retain food. 

Treatment. — Although whooping-cough, like the other infectious 
diseases, is self-limited, its severity can be considerably modified and its 
complications often prevented by appropriate treatment. 

Aero therapy. —The child should spend the greater part of the 
clay out of doors in pleasant weather. If the circumstances permit 
removal to the seashore it is of undoubted benefit. The fine saline 
particles thrown up by the surf give quick relief by being inhaled. 
The sleeping-quarters should be well ventilated, the child being pro- 
tected by screens from direct draughts. 

Drugs. — For the control of the cough in the beginning of the 
spasmodic stage we have had very satisfactory results with the three 
following drugs, fluoroform, the bromids, and antipyrin. The treat- 
ment may be begun by giving two drops of a 2.8 per cent, solution 
of fluoroform every two hours during the day, and after each paroxysm 
during the night, to a year-old child. The dose may be increased by 
one drop for each succeeding year of age. Occasionally this is not 
effectual enough, or apparently the child becomes accustomed to its 
sedative action. The bromid of soda in two-grain doses every three 
hours for a two-year-old child may be substituted. Antipyrin is 
well tolerated, and can safely be prescribed if complications do not 
contraindicate. It may also be combined with the bromids as in 
the prescription given below. A child of six months can be given ^ 
grain of antipyrin at three-hour intervals, 2 grains to a two-year-old 
child. If it is used with the bromids the dosage must be regulated 
accordingly. 

In exceptional instances in which the paroxysms are particularly 
severe and are preventing rest, small doses of heroin, as indicated in 
the prescription below, will give relief for the night. 

19 



290 



DISEASES OF CHILDREN. 




Fig. 79. — The Kilmer belt for pertussis. 



THE INFECTIOUS DISEASES. ' 291 

For a two-year-old child: 

I^ AntipjTini gr.xxxij 

Glycerini oiij 

Aquae q. s. ad. 5ij 

Misce et signa. — One teaspoonful every three hours 
for six doses. 

I^ Sodii bromidi gr. xlv 

Antipyrini gr. xxiv 

Glycerini oiij 

Aquae q. s. ad. sij 

Misce et signa. — One teaspoonful every three hours 
for a three-year-old child — well diluted. 

I^ Heroini hydrochloridi gr. f 

AntipjTini gr. xvj 

Elixiris adjuvantis Sij 

Misce et signa. — A teaspoonful every three hours to 
a child of two years for three doses. 

Diet. — Food should be taken in smaller quantities and at lessened 
intervals than in health. This measure in itself prevents the vomiting 
which readily occurs when a full meal is taken. After vomiting, a 
cup of milk or meat broth may be immediately given. Only simple, 
light and nutritious articles should be permitted in the dietarj^ 

The inhalation of antiseptics has given us no satisfactory results. 
In fact, it tends to encoiu^age poor ventilation in the sleeping apart- 
ment. A belt as suggested by Kilmer can be worn if vomiting is 
frequent. In a certain number of cases this appliance (see Fig. 79) 
has given relief from this distressing symptom. 



Mumps. 

{Epidemic Parotitis.) 

Mumps is an acute communicable disease of the salivarj^ glands, 
characterized by a swelling of the parotid gland and the neighboring 
salivary glands, and at times involving the testis or ovary. 

Etiology. — Children from two to fifteen years of age are most 
often affected. Epidemics are common in schools and institutions. 
The specific contagium has not been isolated. Close contact is 
necessary for its dissemination, but the disease is transmissible before 
the swelling appears. The portal of entry seems to be the buccal 
cavity. The period of incubation is an indeterminate one; it ranges 
from one to four weeks. Immunity is generally conferred by the one 
attack. Recurrences, however, do occur. 

Pathology. — According to Virchow, there is an inflammatory 
serous and cellular infiltration of the intraacinous and periacinous 
connective tissue, which tends to resolution without induration. 



292 DISEASES OF CHILDREN. 

Symptomatology. — In children the onset is usually mild, with a 
period of malaise, drowsiness, fever of one or two degrees (only rarely 
104° F.), chilliness, and sometimes vomiting. A swelling now appears 
below the lobe of the ear on one side of the face and in a few days the 
opposite gland is generally involved. The child complains of a 
feeling of fullness, with pain localized in the angle of the jaw. The 
swellings are elastic on palpation. Mastication is difficult and food 
may be refused for this cause. The fever ranges from 101° to 103° F. 
Occasionally there is earache or deafness. The swelling may extend 
over the parotid in front, or involve the submaxillary gland and the 
neighboring lymph nodes, giving the characteristic rounded appearance. 
The displacement of the auricular lobule with the lobe of the ear in 
the center of the swelling assists in fixing the diagnosis. 

In some instances there is little or no discomfort, and the child 
is not willing to go to bed. After seven or ten days the swelling 
subsides and entirely disappears. Relapses, however, may occur. 
Occasionally the swelling is very large and painful. In exceptional 
instances only, the submaxillary glands may alone be involved. 

Lymphocytosis is quite a constant symptom, especially at puberty 
(Wile). 

Complications. — In boys orchitis is occasionally seen, and the 
same may be said of ovarian pain in girls. The breasts especially 
in girls may be tender. When these complications do occur, the 
child is generally at or near the age of puberty. The lymph nodes 
may become secondarily involved, and suppuration of the affected 
glands take place, but only if there has been a mixed infection. 
Deafness, inflammatory eye diseases and rarely nephritis are com- 
plications which may occur and should be guarded against. 

Differential Diagnosis. — Mumps should not be confounded with 
hypertrophied lymph nodes which present an irregular nodular swell- 
ing and are not found on the face. An examination of the throat or a 
concomitant infectious disease may account for such a swelling. In- 
volvement of the submaxillary glands alone, so-called submaxillary 
mumps, must, however, be considered. If with a history of exposure 
there is a large soft swelling filling up the space between the angle of 
the jaw and the mastoid process, and it hfts forward the lobe of the 
ear, the diagnosis is quite certain. 

Prognosis. — In this benign disease, which is rarely complicated, 
fatalities do not occur, and the prognosis is most favorable. Deafness 
sometimes results and rarely following an orchitis the testicle ceases to 
develop. 

Treatment. — As it is a communicable disease, the children should 



THE INFECTIOUS DISEASES. 293 

be isolated. If there is fever and discomfort, a laxative is given, and 
the child is put to bed. Local anodyne applications of 3 per cent, 
ichthyol-lanolin ointment, or warm oil of hyoscyamus are applied. 
Often a hot-water bag is found to be very agreeable. Mouth-washes 
of listerin or boric acid solution should be used frequently. The 
bowels should be kept freely opened, and a liquid or soft diet ordered. 
Guaiacol ointment (5 to 10 per cent.) is soothing if orchitis is present 
as a complication. The patient may mingle with other children after 
the third week. 

Typhoid Fever. 

Typhoid fever is a specific infectious disease due to the typhoid 
bacillus. 

Etiology. — Infected drinking-water, infected milk, and contact with 
attendants who may be typhoid bacilli carriers are in greater part 
responsible for the infection in children. Irresponsible children 
are liable to drink contaminated water in any place, and especially when 
going about at summer resorts. Infants and young children are 
more liable to infection when they are placed close to the ground or are 
handled and fondled by many adults. Dishes, thermometers, or even 
flies may carry the infective agent. The fall of the year when the 
children return from the country always shows the greatest number of 
cases. The disease is by no means as rare in infants and children as 
was formly supposed. The Widal reaction has revised the figures. 
About 6 per cent, of the cases occur under two years, and 8 per cent, 
under five years, and 46 per cent, between five and fifteen years. 
Typhoid fever may be transmitted from the mother to the fetus. 

Pathology. — As differentiated from the pathology of the disease in 
adults, we have a milder ulceration of the solitary follicles and Peyer's 
patches; and when examined postmortem, it is often difficult to dis- 
tinguish the ulceration from a case of ileocolitis. In infants there may 
be no ulceration whatever. In older children, especially where heal- 
ing has taken place, the '^shaven beard" appearance is sometimes seen 
due to pigmentation. The ulceration rarely penetrates beyond the 
submucosa. This pathologic picture is in distinct relation to the 
milder character of the symptoms as met with in children. The 
mesenteric lymph nodes in the ileocecal region are enlarged. The 
spleen may be enlarged, congested, and soft. The mucous membrane 
of the bronchi and larynx are often involved in varying grades of 
inflammation. The kidneys quite regularly show cloudy swelhng. 
The heart muscle shows mild grades of myocardial degeneration. 



294 DISEASES OF CHILDREN. 

Symptomatology. — The prodromal symptoms are so irregular and 
so apt to be influenced by some one prominent symptom or symptom- 
complex as to lead the examiner astray. 

In infants the mode of onset is quite different from that of older 
children. The infant has an initial high fever which becomes irregular 
or remittent, and subsequently the symptoms resemble a gastro- 
enteric infection. Convulsions are the exception; older children 
who are able to describe their symptoms complain of headache and 
chilliness. Malaise and vomiting are frequently observed. Delirium 
at night, when the fever is high, is seen after a few days. Epistaxis is 
the exception. Cerebral symptoms may usher in the disease. A cough 
is often present quite early and serves to obscure the diagnosis. A 
careful physical examination of the chest by a process of exclusion 
may point the way to an early diagnosis. It will be well to take up 
the symptoms seriatim to give a picture of the varied manifestations 
of the disease, and these will be described in the order of their early 
assistance in diagnosis. 

Roseola. — These spots, which are macules fading on pressure and 
distinctly discrete, are observed in more than 60 per cent, of the cases. 
The eruption is seen as early as the fourth or fifth day, and, as a rule, 
is widely scattered. The abdomen, chest, and back may each show 
them. We have seen hemorrhagic areas on the abdomen, toes, and 
heels in severe or fatal cases.' 

Spleen. — As a rule, the younger the child the less often is the en- 
largement felt early. It is distinctly palpable in the second week. 
The splenic enlargement often persists after convalescence has begun. 
There may be a relapse without an enlargement of the spleen. 

Mouth. — The rather characteristic tongue seen in adults is rarely 
observed in children, and it clears up much more rapidly. Sordes on 
the lips are common. 

The Stools. — These are not necessarily of the pea-soup variety; 
in fact, moderate constipation more often persists throughout the 
disease. 

The Temperature. — The temperature curve is only rarely typical. 
During the first week there is a gradual rise in temperature until the 
maximum point is reached. The fever now assumes a remittent type, 
but it is not unusual to have intermissions. Cases with cerebral symp- 
toms may have a hyperpyrexia for days. 

The temperature curve may last from two to six weeks; occasion- 
ally in protracted cases there is a gradual daily rise; but we feel that 
this fever may be solely due to the asthenia caused by a low diet. 
Complications such as bronchitis, pneumonia, otitis, or even constipa- 



THE IXFECTIOUS DISEASES. 295 

tion may influence the course of the pyrexia causing irregularities in 
the curve. Relapses produce a low-grade temperature after a period 
of normal or almost normal temperature. 

Laboratory Tests. — An early test and one which often gives 
results during the first week is the use of blood cultures made from 
freshly drawn blood. The Widal reaction (see p. 63) is present in 95 
per cent, of the typhoid patients, and may be obtained as early as the 
end of the first week. 

The urine and feces contain the bacilli, and improved laboratory 
methods show their presence in 20 to 50 per cent, of the cases. The 
Ehrlich-Diazo reaction is sometimes present before the Widal reaction, 
and w^hen obtained is confirmatory evidence of the disease, but not 
pathognomonic. 

The Blood. — The red blood-cells and the hemoglobin diminish 
as the disease progresses, but the leukocytes are quite uniformly low 
from the beginning. With the establishment of convalescence, the 
differential count shows an increase in the eosinophiles and mononu- 
clear lymphocytes and a corresponding decrease in the polynuclear 
neutrophiles. 

Pulse. — The relatively slow pulse is obtained only in older 
children, from ten to fifteen years. Infants and young children not 
uncommonly have a pulse rate as high as 150. Irregularity is quite 
frequently noted, while the dicrotic pulse is rare. 

Pain. — It is seldom that this symptom is elicited in young sub- 
jects. In older children it is present in the ileocecal region in a good 
number of cases, and usually is accompanied by tympanites and 
probably is a result of ulcerative processes in the agminate glands or 
Peyer's patches. 

Hemorrhages. — It is rare to have hemorrhages in children. When 
they occur the amount is usually small and more easily controlled. 

The Heart. — Depending upon the amount of toxemia we have 
myocardial changes which may produce systolic murmurs. 

Treatment. Prophylactic. — If children liA^e in vicinities haidng a 
suspected water supply, or remove to such a locahty, precautions 
should be taken to boil the water and to supply an absolutely clean, 
uncontaminated milk. The excreta of the attendants should be 
examined for the possibility of the presence of the bacilli, especially 
if there has been a history of previous tA^ohoid. Weaning or a wet- 
nurse are indicated if the mother herself is infected. 

Further experimentation may prove typhoid vaccination of 
value in institutions or in epidemics. Typhoid precautions should be 
scrupulously observed' even in suspected cases. The feces, urine, 



296 DISEASES OF CHILDREN. 

dishes, and clothing being disinfected with carbohc acid or chlorinated 
lime (as given on page 337). The napkins of infants should be made 
of cheap material and destroyed by burning. 

General Treatment. — Careful, capable nursing far exceeds the 
value of drugs in this disease. A well-kept chart recording the varia- 
tions in temperature, pulse, and respirations, every three or four hours, 
with notes upon the character of the pulse and stools is of great 
importance to the physician. 

The room should be as large as possible and one that can be well 
aired, and in which quiet can be maintained. Two beds so as to 
allow ready change of linen and position are preferable. Scrupulous 
attention should be paid to the mouth, tongue, and teeth, keeping them 
as free as possible from foreign material by the use of swabs dipped in 
mild antiseptic solutions, such as listerin or boracic acid. 

For disinfection of excreta, see section on Disinfectants and 
Disinfection. 

Feeding. — In mild cases in which the temperature is not high, 
and the digestive processes have been little interfered with, milk 
and lime-water, thin gruels, plain or dextrinized, broths made of 
mutton or chicken, orangeade, and lemonade form a list which will not 
be tiresome and which furthermore will fairly well keep up the patient's 
nutrition until he is able to take semisolid food in the beginning of 
convalescence. 

Severe cases with continued high temperature may require the 
peptonization of the milk or the discontinuance of milk entirely, if it 
causes tympanites. Dextrinized gruels, beef broths, and albumin 
water may be substituted. 

In convalescence, in addition to articles already permitted, 
zwieback dipped in broths, milk toast, junket, scraped beef, baked 
custards, and soft-boiled eggs are cautiously added to the diet. Mat- 
zoon and kumyss or home-prepared buttermilk are occasionally relished 
by the child and vary the monotony of his restricted dietary. 

Hydrotherapy. — The fever is in nearly all cases effectively con- 
trolled by sponging with alcohol and tepid water. We have dis- 
continued the use of tubbing. Any good effects of the reduction of 
temperature obtained are more than counterbalanced by the nervous 
excitement it produces. Therefore, a wet pack is preferable for high 
temperatures not controlled by sponging, the sheets being wrung 
out in water at 90° F. If at this temperature a satisfactory reduction 
is not obtained, the wrappings may be sprinkled with water at 85° or 
even 80° F. An ice-bag may be applied to the head, especially if 
there is headache or delirium, but it requires constant vigilance on 



THE INFECTIOUS DISEASES. 297 

the part of the nurse who should be instructed to remove it if any 
cyanosis develops. 

Drugs. — With the exception of certain symptoms which will 
require control by the use of medication, no drugs should be given. 
Intestinal antiseptics and alcohol as routine measures are to be 
deprecated. The bowels are kept open with saline enemas which 
may be given cool if the temperature is high. Divided doses of 
calomel are indicated in the beginning of the disease. Tympanites 
should be prevented rather than treated by careful supervision of 
offending articles of diet, especially the milk. Headache and rest- 
lessness if not sufficiently allayed by the hydrotherapeutic measures 
can be subdued by the use of the bromides. Alcohol is given in the 
form of sherry wine or whisky if the pulse is weak or the reaction is 
not good following a pack. Strychnia, grains -g-^, tincture of digi- 
talis or strophanthus, in two- minim doses, or brandy hypodermatically 
are given if collapse threatens. If hemorrhage occurs, a light ice 
bag or coil is immediately applied to the abdomen and Dover's 
powder in maximum doses given. The treatment for perforation 
which would be evidenced by sudden pain, abdominal tenderness, and 
changes in the rational signs demands prompt surgical intervention. 



Influenza. 

{Acute Catarrhal Fever. La Grippe.) 

Definition. — An acute, specific, infectious disease affecting the 
respiratory or gastrointestinal tracts, and usually associated with 
marked prostration. 

Etiology. — While the disease is endemic, especially in damp, cold 
weather, it is ver}^ frequently seen in epidemic form. The immediate 
cause is a small bacillus first isolated by Pfeiffer in 1892. The bacillus 
may be localized in the mucous membrane of the nose, throat, or lungs. 
Other pyogenic bacteria may be present with the influenza bacillus, 
thus giving a mixed infection. Pfeiffer's bacillus resembles a diplo- 
coccus, having rounded extremities and staining markedly at the ends. 

Incubation. — From tweh^e hours to three days. 

Pathology. — There is some inflammation in nearly all the mucous 
membranes. In addition to this, complicating inflammations may 
exist in the heart, lungs, middle ear, mastoid process, kidneys, and 
gastrointestinal tracts. Meningitis has occasionally been reported 
as caused by the influenza bacillus. Tuberculosis may also follow 
an attack of influenza. A marked general depression often accom- 



298 DISEASES OF CHILDREN. 

panying influenza is doubtless caused by the toxins secreted by 
Pfeiffer's bacillus. 

Symptomatology. — Although young infants are not particularly 
susceptible in contracting the disease, yet when they are attacked it is 
apt to assume a grave form with high temperature and great prostra- 
tion. The younger the child, the more severe is usually the infection. 
In older children the average clinical description of symptoms as affect- 
ing principally either the respiratory, digestive, or nervous systems 
will hold good. It is true, however, that these varying symptoms 
will often be found combined in a given case. 

Inflammatory disturbances of the respiratory tract predominate in 
children. There is marked coryza with an acrid discharge that may 
excoriate the upper lip. A general pharyngitis is also present, the 
mucous membrane presenting a thickened, spongy appearance. The 
tonsils may be swollen and show white points of exudation in the 
crypts. In a word, there is a severe general rhinopharyngitis present 
that is prone to involve the Eustachian tubes and middle ear, with a 
secondary enlargement of the lymph nodes that are connected with this 
region under the ear and back of the jaw. 

These disturbances are evidently more virulent than the ordinary 
inflammation met with in this region. This is not only seen locally, 
but in the disposition of the process to extend downward. In some 
ways this is analogous to the course of measles. The larynx, trachea, 
and bronchi are quickly involved, but in many cases the inflam- 
mation does not extend below the larger or medium-sized tubes. 
The cough may assume a paroxysmal character simulating pertussis. 
In others there is involvement of the small tubes and alveoli 
coming on soon after the onset of the disease. This type of broncho- 
pneumonia is much like the ordinary form as far as physical signs 
are concerned, but early prostration is more marked and the tem- 
perature is usually irregular and higher than the local lesion 
would seem to warrant. True lobar pneumonia is also not infre- 
quently seen, and, as in most influenza conditions, exhibits disturb- 
ances of temperature and circulatory and nervous depression out of 
proportion to what would be expected from the pulmonary signs. 
Perhaps the most frequent exhibition of pneumonia is seen in the form 
of irregular patches with sneaking invasion, when it is very difficult 
to decide the exact nature of the pneumonic process. 

Various grades of pleurisy are frequent accompaniments of pneu- 
monia, and empyema may be the terminal condition. This must be 
constantly borne in mind as this empyema is even more insidious than 
usual, especially in infants. 



THE INFECTIOUS DISEASES. 299 

In cases where the gastrointestinal symptoms predominate there 
may be severe vomiting and the passage of loose, undigested stools. 
Nourishment is badly taken and after an interval the stools may con- 
tain mucus and even blood. The gastroenteric symptoms may ap- 
pear at the very beginning of the attack, or later during the course of 
the disease. While under proper dietetic and medicinal treatment 
these symptoms may not last beyond a few days, they naturally add 
to the prostration, and in young and feeble infants may predispose 
to a fatal ending. 

The cases in which pure nervous disturbances preponderate over 
the inflammatory symptoms do not seem to be so common in early life. 
Some severe cases may start with convulsions and simulate meningitis 
with photophobia, stupor, and, in older children, headache and deli- 
rium. In uncomplicated cases, however, these marked nervous dis- 
turbances do not last longer than a few days. Cases have been 
reported where true cerebral meningitis appears to have been 
caused by the influenza bacillus. The writer has seen a number 
of cases of plain clinical cerebrospinal meningitis where the fluid 
from a lumbar puncture showed neither the meningococcus nor the 
pneumococcus. It is possible that such cases are due to the influenza 
bacillus. 

Some of the clinical phenomena, aside from the types just men- 
tioned, may be noted. The fever is apt to be irregular and at times 
very high, especially in young infants. In some cases, fever and pros- 
tration will be the principal symptoms of the disease with little evi- 
dence of any local inflammation. In other cases, an irregular fever 
may last for several weeks and simulate typhoid fever. Here all the 
modern diagnostic methods must be employed in order to make a 
proper diagnosis. A further confusion will be caused by intestinal and 
diarrheal symptoms sometimes accompanying these prolonged cases. 
Some of the protracted cases are quickly relieved by change of air, 
particularly to a location where influenza is not so prevalent. 

The skin is sometimes involved, with various forms of erythema. 
This may at times simulate measles or appear in scarlet form. The 
irregular character and distribution of the eruption, with entire ab- 
sence of desquamation, and existing in connection with the various 
symptoms of influenza will throw light on its character. 

The urine will frequently show traces of albumin in influenza. 
It is probable that this has no great significance. Cases have been 
reported in which acute nephritis has supervened. Rachford states 
that if nephritis exists as part of the influenza attack the worse symp- 
toms occur early, and that if the life of the child is not destroyed 



300 DISEASES OF CHILDREN. 

within the first week of the disease, a sure and steady improvement 
begins which leads to complete recovery. 

Diagnosis. — In diagnosticating this disease, the bacteriological aid 
is not so great in practice as it is in theory. The bacilli are difficult 
to discover, and frequently disappear early in the disease. Not 
only are they very hard to find in smear, but their culture requires 
a blood serum which may be difficult to procure. Accordingly, in 
the great majority of cases, the physician must depend entirely on 
clinical signs for a diagnosis. In some cases he has to rely largely on 
a process of exclusion. Wherever an illness quickly shows a prostration 
out of proportion to the apparent lesions, influenza may be expected. 
The tendency to spread through a family is suspicious, as the disease 
is highly contagious. This will be helpful in children, as adults 
usually contract the disease first, and the physician on being informed 
of this will be helped in making his diagnosis. There are nearly 
always inflammatory symptoms in the nose and throat to help the 
diagnosis. The onset of acute tonsillitis or pneumonia will often cause 
confusion. The former usually has a higher temperature and a more 
abrupt onset, while the latter should show physical signs early in the 
attack. A central pneumonia, however, may require several days for 
a differentiation from influenza where both are suspected. In some 
cases, the course of the disease, with presence or absence of local lesions, 
will be all that will clear up the diagnosis. 

When influenza is epidemic probably other conditions are oftener 
explained wrongly as due to this cause than vice versa. At any rate, 
a knowledge of its prevalence will put the physician constantly on 
guard in examining and diagnosticating obscure symptoms accompanied 
by prostration. 

Treatment. — The first thing called for is isolation of the patient 
as far as possible, to prevent the disease spreading through the family. 
The room should be well ventilated with plenty of fresh air, as this 
not only supports the patient, but tends to prevent reinfection as well 
as the direct spread of the infection to others. Close, badly ventilated 
rooms often seem to hold the infection for a long time. The child 
should be kept quietly in bed, even in mild cases, and simple, easily- 
digested nourishment given. When the fever is high, reliance should 
be placed rather on frequent spongings with cool or tepid water and 
alcohol than on the coal-tar derivatives. If there is much restlessness 
with the fever, small doses (one or two grains) of phenacetin with 
citrate of caffein may be given for a few doses at least. Where pain 
is evident, sulphate of codein, gr. -3V to gr. -gV, for an infant of one 
year may be administered every three or four hours. For support 



THE INFECTIOUS DISEASES. 301 

and stimulation, sulphate of strychnin is most valuable, gr. ^^ to 
gr. -3-^-0 every three or four hours for an infant of one year. From ten 
to twenty drops of whisky or brandy may also be given when the 
pulse is weak. The bronchitis, pneumonia, or gastroenteritis are to 
be treated as when occurring as primary conditions except that sup- 
port and stimulation must be specially emphasized on account of the 
extra depression of the influenza. When the attack is prolonged or 
tending to constant recurrence, a removal to another section of the 
country may be the quickest way to recovery. Fumigation of apart- 
ments in which a patient has been long sick may also tend to prevent 
reinfection or the spread of the disease. 

Syphilis. 

Definition. — Syphilis is a communicable disease that may be 
acquired by inheritance or by direct contact after birth. In the 
latter case there is always an initial lesion, the chancre, followed by 
numerous secondary lesions, affecting principally the skin and mu- 
cous membranes, and by tertiary symptoms involving the bones, 
viscera, and the organs of the special senses. In hereditary syphilis 
there is an absence of the initial lesion and the disease shows itself in 
the secondary form from the beginning. 

Hereditary or Congenital Syphilis. 

Definition. — This is a form of the disease in which the infection is 
derived from the father or mother or both. 

Method of Transmission. — Our knowledge of the transmission of 
this disease has recently been greatly increased by means of the Wasser- 
mann reaction. It seems probable that the mothers of all children 
having congenital syphilis are themselves syphilitic. Knoepfelmacher 
in a study of forty-five cases found that 56.2 per cent, gave a distinctly 
positive Wassermann reaction. More than half of these cases never 
gave any symptoms of nor were ever treated for syphilis. The mothers 
of children having syphilis give as high a percentage of positive 
Wassermann reactions as do men who have reached the latent stage 
of syphilis. 

A positive Wassermann reaction in the mother lessens the possi- 
bility of the child being born sound. A mother may during a period 
of latency or of vigorous treatment give birth to a sound child, even 
though she at some later time again develops active symptoms. When 
the mother is suffering from acute syphilis it is transmitted in an active 
form to the child. The degree of such transmission depends upon the 



302 DISEASES OF CHILDREN. 

stage and severity of the disease and the nature of the treatment 
employed. 

The apparent immunity of the mother in fact does not exist, for 
if she bear a syphilitic child she herself is syphilitic. Colles' dictum, 
therefore, that ^' a new-born child affected with inherited syphilis, 
even though it may have symptoms in the mouth, never causes ulcera- 
tions of the breast which it suckles, if it be the mother who suckles it, 
although continuing capable of infecting a strange nurse" has been 
practically proven to be a fallacy. Profeta's law is likewise in error, 
for every child born of a syphilitic mother, no matter how healthy in 
appearance, is syphilitic if the mother shows any active symptoms 
of the disease. 

It is now almost a certainty that syphilis is never transmitted 
through the spermatozoa of the male. The disease is transmitted 
from father to child through the mother. A positive Wassermann 
reaction is obtained much less often in the father than in the mother, 
this probably being due to the fact that syphilis is in a majority of cases 
a self-limiting disease, the dangers of transmission after the fourth or 
fifth year being greatly diminished. 

Pathology. — The spirocheta is widely distributed in the infant's 
body. According to Trinchese, they are found most abundantly in 
the suprarenals, then in the liver, lungs, ovaries, testes, spleen, the 
fetal end of the funis, and also with relative frequency in the blood. 
They are relatively rare in the placenta, but may be found in the 
stroma and on the surface of the villi. The migration of the spiro- 
cheta from the vessels of the villi to the surface of the villi and into 
the intervillous spaces is regarded by Trinchese as normal. 

The spirocheta can, as a rule, be easily demonstrated in any of the 
superficial ulcerating areas by the ''india-ink method" of Hech and 
Wilenko. A small drop of serum is pressed out of the tissues and 
placed upon a slide. To this is added a similar sized drop of india ink 
(Gunther's and Higgin's) and thoroughly mixed with a platinum loop. 
The mixture of serum and ink is allowed to dry, after being spread out 
as thinly as possible. This smear is then examined under an oil-im- 
mersion lens. 

The fetus may die any time during uterogestation with result- 
ing miscarriages, or may live to term and then be still-born. When 
born alive, the lesions resulting from the disease may be broadly 
divided into those involving the skin and mucous membranes, 
the viscera, and the bones. There may be erythema, maculo-papules, 
or papules on the skin, or a vesicular and pustular eruption may 
occasionally be seen. Blebs or bullae often appear at birth in a 



THE IXFECTIOUS DISEASES. 303 

severe type of the disease. Crops of boils, with well-defined, coppery- 
red bases are apt to be symmetrically arranged when many are present, 
or asymmetrically distributed if only a few are seen. The lesions of 
the mucous membranes may take the form of inflammatory processes, 
of mucous patches, or of superficial or deep ulcerations. The junction 
of skin and mucous membrane is a favorite seat for the syphilitic lesion. 
The viscera are more apt to be involved in hereditary than in acquired 
syphilis, the lesion taking the form of an interstitial hyperplasia. 
The growth of interstitial connective tissue, which, by gradual con- 
traction, partially obliterates the parenchyma of the organ, may in- 
volve the lungs, spleen, liver, pancreas, and testicle. Usually a portion 
of a lobe, but occasionally a whole lobe of the lung may present a diffuse 
fibroid infiltration with a grayish-white color. The liver, which is not 
infrequently affected, is hardened and enlarged from a diffused scle- 
rosis, although occasionally the affection may be circumscribed. Gum- 
mat a, in the form of small, circumscribed noclules may be found in the 
lung, liver, or other viscera. Bone lesions are quite common and some 
that were formerly referred to rickets or scrofula are now recognized as 
syphilitic. There are two principal ways in which the specific poison 
affects the bones in early life. In one instant the brunt of the disease 
and morbid change takes place at the junction of the shaft with the epi- 
physis — osteochondritis; in the other, the periosteum covering the long 
bones is principally affected with a resulting periostitis. Both of these 
varieties involve principally the long bones. Osteochondritis develops 
early in life, usually within the first month. It may, however, occur 
later, when it is not apt to become multiple, and may be unsymmetrical 
in distribution. While epiphyseal swellings may be due to rickets as 
well as syphilis, such swellings are pretty surely syphilitic if they occur 
during the first six months of life and they are relieved by mercurial 
treatment. Again, the epiphyseal swellings of rickets are always sym- 
metrical, while those of syphilis may be unilateral. Periostitis occurs 
later in hereditar}^ syphilis, usually after the child has begun to walk. 
It attacks by preference the femur, tibia, and bones of the forearm, 
occurring usually from the second to the fourth or fifth j^ear. At an 
early stage of the disease the bones are attacked S3^mmetrically, but 
later, circumscribed nodes may be placed unilaterally. 

A dactylitis attacking by preference the proximal phalanges of the 
metacarpal and metatarsal bones, enlarging them to several times their 
natural size, may occur. There is not much destruction of bone but 
after a time the skin may become inflamed and break down from the 
formation of an abscess. Craniotabes may result from the malnutri- 
tion of syphilis as well as from rickets. 



304 



DISEASES OF CHILDREN. 



Symptomatology. — The symptoms vary greatly in severity from 
cases showing good nutrition and one or two slight lesions only to such 
severe infection as to produce early death. In the latter case, the 
fetus may be attacked in the uterus resulting in abortion more or less 
early in pregnancy. As the disease lessens in severity in one or both 
parents the pregnancies will be longer in duration and finally an appa- 
rently healthy infant may be born. While there may be evidences of 
syphilis at birth, the onset is often delayed until weeks or months 
afterward. In the majority of cases the primary symptoms will be 
noted before the end of the second month. The earlier the disease 
manifests itself after birth, the graver will be the nature of the attack. 




Fig. 80. — Congenital syphilis. 



Very early syphilis is usually accompanied by emaciation, severe coryza, 
cracked and ulcerated lips, eruptions of bullae, particularly upon 
the palms of the hands and soles of the feet, and evidences of visceral 
and bony disease. In the older cases there may be no apparent inter- 
ference with nutrition, and possibly one or two mucous patches may be 
the only active manifestations of the disease. As noted in the path- 
ology, almost any structure of the body may be involved in the course 
of the disease. 

The skin rashes often develop rapidly and are apt to be less sym- 
metrical than those seen in adults; they are likewise polymorphous, as 
several different forms of eruption may be exhibited at the same time 



THE INFECTIOUS DISEASES. 



305 



in a given case. There may be first an eruption of small round pink 
spots, disappearing on pressure, and usually appearing first on the 
lower portion of the abdomen. These may later take on a coppery 
discoloration. A papular syphilid may be seen in the form of small 
or large flat papules which are not so apt to group themselves into lines 
and circles as in older subjects. Neither are they so solid and deeply 
infiltrated as in the adult. Upon the palms and soles these papules 
may be very abundant and fuse together, presenting a thickened, dull- 
red surface. The vesicular syphilid is not common; the vesicles may 



• 




1 


1 


■ 


\ 






,;-.'-=^-^>:Ki / ' 


'\ 


{ 








-Wh^^ 


^>&- -.^ 


.< 


.---^,/ 












h 


; 




io''-^-:^^ 






''~' 


} , 


,^j 


,-^'^ 




■"^rl^ 


:-!^ 


^ 


:rC 








"\- "^ -^ 


s 


r 


-.•■■ 


y 


\, 


'■-,'-■. - >• •■'-' 




'-'% 








-- .-i--- s - /^ 


'■ ) ^ " ,_ ■■ *- 










V 


gi;-^' " r:-- 


vk-^' :// 




/ 


/ 










// 


k'. 










^--"-^ 











Fig. 81. — Section of liver from syphilitic infant, showing large numbers 
of spirochetae. — {Chapin.) 



be associated with pustules, and appear in closely-arranged groups 
about the mouth and chin or various other parts of the body, especially 
the nates and hypogastrium. Pustules may appear on the face, but- 
tocks, and thighs. Pemphigus is seen only in the severer forms of the 
disease and then preferably on the palms of the hands and soles of the 
feet. A smoky discoloration of the skin, seen most distinctly in the 
prominent parts of the face, such as the eye-brows, cheek-bones, and 
bridge of the nose may occasionally be the only manifestation on the 
skin. There is apt to be a dryness of the skin which may hang in loose 
folds from the general cachexia. 
20 



306 DISEASES OF CHILDREN. 

The mucous membranes are early effected. One of the most 
typical symptoms is the coryza. At first there may be a serous 
discharge which gradually becomes worse until the nasal secretion 
takes on a purulent or even a bloody character with excoriations 
of the upper lip. The secretion may become inspissated, forming 
crusts, which may completely block up the nasal passage. There is 
often flattening of the bridge of the nose from interference with respira- 
tion. Mucous patches are oftenest seen in the mouth, about the nose, 
upon the scrotum, vulva, labial commissures, and occasionally at the 
umbilicus. Deep fissures sometimes form at the corners of the lips, 
even extending well out into the cheek. There may be enlargement of 
the epitrochler, cervical, cervicomaxillary, axillary, and inguinal 
lymph-glands but there is not a general adenopathy. Condylomata 
are sometimes found about the anus. 

The long bones should be carefully examined for enlargement and 
thickening of the epiphyseal and distal ends. The epiphysis may even 
be separated from the shalt, when crepitation will be found upon care- 
ful handling. Dactylitis is usually confined to one phalanx which will 
be enlarged to double its normal size, but there is not apt be much 
involvement of the soft parts; several phalanges are sometimes 
attacked. Onychia, ofted followed by ulceration around the nail, 
is occasionally seen. The first teeth are delayed, poorly developed, 
and will probably undergo early decay. 

A profound anemia is sometimes seen, characterized by a diminu- 
tion and alteration of the red blood-corpuscles, the appearance of 
megalocytes and microcytes and of nucleated erythrocytes. There 
is leukocytosis which may become extreme. 

There may be sufficient disturbance of nutrition to induce an 
atrophy of all the structures of the body, the infant presenting a 
weazened appearance. This is oftenest seen in bottle babies and 
some infants that are nourished on the breast may remain plump 
and well-nourished throughout the course of the disease with only a 
few mucous patches to give evidence of a mild infection. 

Diagnosis. — It is usually easy to diagnosticate the disease from 
some of the pathological or clinical manifestations just described. In 
cases of marasmus, if there has been no chronic indigestion, partic- 
ularly if the infants have been fed on the breast, syphilis may be sus- 
pected. Chronic coryza is suspicious and mucous patches will make 
certain a diagnosis. The following points are characteristic of syphi- 
litic lesions: They are general in their distribution, but ambulatory 
and changing, and usually present a reddish-brown tint; where crusts 
form they are fairly thick, with a tendency to accumulate in layers, 



THE INFECTIOUS DISEASES. 



307 



and when cicatrices form tlie}^ are smooth and long surrounded by a 
pigmented areola. The bony lesions of syphilis, tuberculosis and 
rickets may be confused. ]\Iorrow gives the following points of differen- 
tiation between syphilis and tuberculosis: 1. Syphilis exhibits a 
marked predilection for the long bones; its habitual localization is in 
the diaphysis, and almost always at its terminal extremity. Tuber- 
culosis is almost exclusively situated in the epiphyses, rarely affecting 




Fig. 82.— Syphilitic dactylitis. 



the shaft. 2. In syphilis there is a marked enlargement of the bone 
by more or less voluminous tumors or hyperostoses, with little or no 
involvement of the soft parts; in tuberculosis the tumefaction is due 
less to increase in the size of the bone than to edematous infiltration of 
the soft structures. 3. In syphilis there is little tendency to suppiu-a- 
tion and necrosis; in tuberculosis the pyogenic tendency is marked. 
4. In syphilis, osteocopic pains, with tendency to noctiu-nal exacer- 



308 DISEASES OF CHILDREN. 

bation are a pronounced feature; in tuberculosis the pain is dull and 
heavy, not aggravated at night. 5. The osseous lesions of syphilis 
rarely react upon the general system, while those of tuberculosis often 
deterniine a niarked impairment of the general health. 

In differentiation of syphilis from rickets, epiphyseal swellings 
under six months are very apt to be syphilitic. In syphilis the epiphy- 
seal swelling may be unilateral, but it is always symmetrical in rickets. 
In doubtful cases the swelling must be subjected to specific treatment. 
It is well to remember, however, that rickets and syphilis may coexist 
in the same case. 

Prognosis. — The earlier the symptoms appear after birth, the 
severer will be the type and the worse the prognosis. Breast-fed 
infants have a much better chance than those artificially fed. If the 
digestion remains good and the manifestations of the disease are not 
severe, complete recovery takes place and the infant may grow up 
healthy and strong. The average prognosis, however, is bad. Kas- 
sowitz states that one-third of all syphilitic children die before birth, 
and among those who are born 34 per cent, die in the first six months 
of life. 

Treatment. — Parents who exhibit any specific symptoms or who 
have had syphilitic children should be subjected to specific treatment 
in the hope of avoiding infection of the fetus. Mercury is the specific 
remedy and may be administered to the infant either externally or 
internally. Daily inunctions of mercurial ointment, mixed with from 
two to eight times its quantity of vaseline or rose ointment, may be 
employed. A lump about the size of a small hickory nut may be 
rubbed on the inside of the thighs or in the axillae, the parts having 
previously been cleansed with soap and warm water. It is more cleanly 
to apply five drops of a 10 per cent, solution of oleate of mercury 
three times daily. Internally, mercury with chalk is one of the best 
preparations in doses of one-fourth to one grain three times a day. 
Calomel, in doses of ^V "to i grain, three times daily, will have 
a more rapid action when such is desired. Or bichlorid of mercury 
Y^-Q to g-\ grain may be given. If the latter induce intestinal irrita- 
tion, a menstruum, containing bismuth and pepsin, will usually allay 
it. When mercury is given for a long time it is well to occasionally 
change its form, although in syphilis is it a tonic, acting like iron in 
anemia. The nostrils must be kept clear, using, if necessary, some bland 
oil like albolin. Mucous patches and excoriations must be kept clean 
and dusted with calomel and bismuth, equal parts. It is usually neces- 
sary to give mercury for at least a year, with occasional intervals of 
tonic treatment. In visceral lesions and where the bones are involved 



THE INFECTIOUS DISEASES. 309 

and evidence of gumma in any part of the body appears, iodid of potas- 
sium, in doses of 1 to 5 grains, will be indicated. The general care 
and feeding is most important. While the infant should not, if 
possible, be taken from the mother's breast, it must never be given to 
a wet-nurse. 

Ehrlich's Preparation. — Recently there has been placed upon the 
market a drug, under the trade name of Salvarsan. This drug is an 
arsenic preparation, and must be given in large doses in order that it 
may produce its effects quickly, as otherwise the spirocheta become 
''arsenic fast," i.e., are not affected by arsenic. 

Salvarsan is not without special danger when given to children 
suffering from congenital syphilis. Following the injection there is 
often improvement for two or three days, and then death follows ap- 
parently as a result of the endotoxins which are set free by the destruc- 
tion of the myriads of spirocheta which exist in the entire body of the 
infant. Another danger following the injection of Salvarsan into 
infants is the formation of a slough. Some observers have noticed a 
rapidly progressive atrophy following the use of this drug. The dose 
which is commonly recommended for direct injection into children is 
0.008 to 0.01 grams per kilogram of body weight. 

More recently it has been suggested that the same effects could be 
obtained by an injection of Salvarsan into a syphilitic mother or wet- 
nurse. A few cases have been reported in which remarkable results 
have been obtained. The improvement of the condition of the child 
is apparently not due to the excretion of salvarsan through the milk 
as no arsenic can be demonstrated, but rather to the formation of anti- 
toxins in the mother, which are excreted through the milk. If this 
method is successful it puts the child in a position to receive a direct 
injection with the least possible danger. 

Both methods have been tried by us in the babies' wards of the 
Post-Graduate Hospital with results that have not been at all brilliant. 
The improvement which followed either method was apparently tem- 
porary. It may be that repeated injections with smaller doses may 
later give better results. Further study under careful oversight is 
required before the possibilities and dangers of this powerful remedy 
can be determined as far as the congenital form of syphilis is concerned. 

Late Hereditary Syphilis. 

This form of syphilis comprises those cases in which early evi- 
dences of the disease have either not existed or have been in such slight 
form as to have been overlooked. Late hereditary syphilis may mani- 



310 



DISEASES OF CHILDREN. 



fest itself either in certain active lesions plainly to be attributed to 
this condition or by certain developmental defects that may easily 
be confused with tuberculosis or rickets. 

The secondary teeth are affected in a way that has been consid- 
ered pathognomonic. The principal change is noted in the two 
superior middle incisors, which are small, peg-shaped with scooped-out 
grinding edges, and placed at such an angle that the cutting borders, 




Fig. 83. — Hutchinson'steeth. {Dr. FrauenthaV s case.) 



if continued, would meet. They may occasionally be deflected out- 
ward, and are known as Hutchinson's teeth (Fig. 83). Ulceration of 
the palate, usually, beginning in the center, may take place and be fol- 
lowed by caries or necrosis of the bone. There may be simultaneous 
or consecutive deep ulceration of the soft palate, pharynx, and naso- 
pharynx at any time previous to the age of puberty. Large, indolent 
mucous patches may exist in the mouth, and there may be ulceration 
about the lips leaving long scars, especially at the commissures of 
the lips. The nasal bones may become necrotic with depression of 
the bridge from destruction of the bony arch. 



THE INFECTIOUS DISEASES. 311 

A periostitis, accompanied by a thickening on the surface of the 
bone, may involve the long bones, especially the tibia, ulna, radius, 
and humerus. The lesion may be multiple and symmetrical, although 
occasionally unilateral. Gummata, involving the bones and occasion- 
ally the soft tissues, may be seen, and, in the latter case, may break 
down with ulceration and leave large scars. Interstitial keratitis, 
without much congestion of the conjunctiva, is not infrequent, and is 
liable to be followed by corneal opacities; although primarily attacking 
one eye, it may involve the other. There may coexist an indolent 
iritis without the usual severe pain and photophobia. A chronic form 
of otitis may be followed by deafness. Painless enlargement of one 
or both testicles may be caused by syphilis, but there will be apt to be 
lesions in other parts of the body to aid in the diagnosis when this 
occurs. In many cases all the evidence of syphilitic taint in child- 
hood will be found in arrested and perverted development. As an 
example, the testicles at puberty may be about the size seen in very 
early childhood, and in girls in absence of mammary development, 
delayed menstruation and a non-appearance of hair on the genital and 
axillary region may be noted. 

Treatment.— The treatment of the later forms of syphilis must 
depend on the activity of the morbid process. Mercury in some form 
should be exhibited when there is any evidence of active syphilitic 
disease. lodid of potash is also to be given in fair doses, three to 
five grains. If there is no evidence of an active syphilitic process, 
the treatment will resolve itself into improving the nutrition of the 
child in every way. Good food, tonics, iron, cod-liver oil, and change 
of air when possible are all of value in aiding healthy growth and 
development in these retarded cases. 

Acquired Syphilis. 

The syphilis detected in early life, although usually hereditary, 
is not necessarily so, but may be acquired. A primary sore upon the 
genital tract of the mother can possibly infect the infant during birth. 
The nurse or attendant may have a primary lesion upon breast or 
lips. Much more common will be infection from some secondary 
lesion, especially a mucous patch upon the mouth or lips. There are 
many ways in which the blood or infective secretions of a syphilitic 
patient may come in contact with a solution of continuity in the skin 
or mucous membranes of an infant or child. A chancre will then 
appear at the point of contact, followed in due time by the later 
manifestations of the disease. Rarely, in older children, the disease 



^12 DISEASES OF CHILDREN. 

may be contracted by sexual contact. The symptoms and treatment 
present essentially the same elements as in adult life, and hence will 
not be considered here. The acquired disease in the infant or young 
child tends to be milder than the hereditary form in its symptoms and 
less apt to affect seriously the general health and development. 

Epidemic Cerebrospinal Meningitis. 

(Cerebrospinal Fever.) 

This form of meningitis is an acute infectious disease due to the 
diplococcus intracellularis, characterized by motor and sensory 
cerebral and spinal symptoms. 

Etiology. — The disease, without question, has its specific germ 
in the diplococcus intracellularis meningitidis, first fully described by 
Weichselbaum in 1887. 

This organism, fortunately of low resistance, gains access to the 
general system through the blood or through some local determination 
in the nasopharynx, ear, or eye, and in those with depleted vitality 
and lowered resisting force finds suitable soil for its propagation. 
It usually occurs in epidemic form, although occasional sporadic cases 
are seen from time to time, especially in the large centers. 

The spring of the year, after prolonged confinement to ill-venti- 
lated and superheated apartments, finds the greatest number of pre- 
disposed individuals. It is essentially a disease of the young. Our 
youngest case was twelve weeks old, although Rotch, of Boston, 
reports a case six days old. The second year claims the greatest 
number of victims. 

Pathology. — In making postmortem examinations of those 
dying with the disease, we find, as a rule, an exudative inflammation 
of the pia arachnoid of the brain and spinal cord. The amount of 
infiltration found, however, often does not correspond to the gravity 
of the symptoms observed during the life of the patient. The degree 
of infiltration varies from an intense hyperemia to a fibrinoplastic 
seropurulent or purulent exudate. This exudate is most marked at 
the base of the brain and along the fissure of Rolando and the dorsal 
portion of the cord. In the ventricles is found a cloudy or opaque 
serum and in a few cases pure pus. The effusion in the subarachnoid 
space (and it must always be kept in mind that there is more fluid in 
the subarachnoid space in children than in adults) is increased in 
normal amount. Frequently there is seen a parenchymatous degen- 
eration of the kidneys, degeneration of the heart muscle and the 



THE IXFECTIOUS DISEASES. 313 

muscles in general. There will also be found in a number of cases 
multiple abscesses, septic joints and ecchymoses of the skin as a result 
of complicating conditions. 

Symptomatology. — In cerebrospinal meningitis the symptoms 
vary according to the type of the disease present. The onset is 
usually sudden and abrupt. The malignant types are seen largely 
in the epidemics only, and are responsible for the large mortality 
record. Headache, vertigo, vomiting, and high fever are soon followed 
by coma and death. 

The symptoms in the sporadic cases will vary with the gravity 
of the local lesion and the intensity of the toxemia. This history of 
the prodromal period may be of material assistance in establishing the 
diagnosis; there is malaise, headache, chills, loss of appetite, body 





'^^ '^^-~" " (p^ 





Fig. 84. — Cerebrospinal meningitis with marked opisthotonos. 

pains, and some rise of temperature. Later frontal headache is com- 
plained of and succeeded by vomiting, restlessness, and rapid pulse. 
Herpes on the lips and nose, retraction of the posterior cervical group 
of muscles, hyperesthesia and opisthotonos are observed. The 
general nutrition suffers severely and emaciation is steady and pro- 
gressive. Delirium, stupor, or profound coma develop. Convul- 
sions of a severe type (particularly in infants and younger children) 
are apt to occur at or near the beginning of the disease. The loss 
of flesh and strength is rapid and marked. Photophobia and irregu- 
larity of the pupils with loss of pupillary light reflex and nystagmus 
are quite regularly present. Neuroretinitis is found on ophthal- 
moscopic examination of the fundus in some cases. The respirations 
vary with the stage of the disease; they are increased when the fever 
is high, sighing and shallow when stupor begins and are irregular 
when coma develops. The blood shows a leukocytosis rarely under 
25,000 to the cubic millimeter. The temperature curve is not char- 
acteristic and bears no relation to the prognosis. The excursions are 



HP 



314 DISEASES OF CHILDREN. 

wide and varied. The pulse is rapid and sometimes irregular. Ecchy- 
motic spots and purpuric areas are seen in some of the fulminating 
cases, but a roseola or an erythema is more apt to occur in the sporadic 
cases. 

The reflexes will help to establish the diagnosis, but must be 
interpreted with caution. The tache cerebrale is always obtained, 
but is only a minor confirmatory sign. The Babinski reflex, or 
extension of the great toe on irritating the plantar surface of the foot, 
is confirmatory, but valueless in children under two years of age, 
although negatively it may be of assistance. Kernig's, sign, which is 
obtained in nearly all the cases at some stage or other, is also present 
in all forms of cerebral irritation. 

Macewen's sign, or the hollow note elicited by percussion over the 
parietal bone, is obtained only in those cases in which fluid has 
accumulated in accessive quantity in the ventricles. The rigidity of 
the neck with dilatation of the pupils when attempts are made to flex 
the neck is also a helpful and confirmatory sign of meningitis. 

The urine in the course of the disease often contains albumin and 
hyalin casts, the result of toxic substances in the blood stream. 
Loefler and Gourand, of France, have lately called attention to the 
fact that in the beginning of the disease large amounts of urine of low 
specific gravity are passed, containing a high percentage of urea. 
An examination of the blood will assist in making a differential 
diagnosis. Leukocytosis, principally of the polymorphonuclear cells, 
is present, while the mononuclear elements predominate in the tuber- 
culous type of meningitis. 

Lumbar Puncture. — Although the diagnosis can often be made 
from the clinical phenomena alone, confirmation and temporary 
relief from intracranial pressure symptoms are afforded by lumbar 
puncture, and it is also an aid in establishing the diagnosis and prog- 
nosis. The procedure is not difficult, and if performed with aseptic 
precautions and a due regard for the anatomy, is productive of no 
harmx. The technic is as follows (see Fig. 15, page 55) : 

Infants in whom opisthotonos has not yet developed may be placed 
over a pillow at the end of a table, the spine and outlying soft parts 
being thus put on the stretch. The spine may be entered between the 
third and fourth lumbar vertebrae. This space is found by an imagi- 
nary line drawn across the iliac crests and intersecting the spine. In 
older patients, or those with opisthotonos, it is necessary to place them 
on their side and enter to one side of the median line. The needle of 
an ordinary good-sized aspirating syringe cannot be improved upon 
for the procedure. A small trochar and cannula may also be used and 



THE INFECTIOUS DISEASES. 315 

10 to 15 c.c. (h ounce) should be withdrawn, provided the fluid flows 
freely, as this amount will include fluid from the cranial cavity and 
lead to more accurate bacteriological results. It is not wise to with- 
draw more than 30 c.c. or an ounce at a sitting. In infants with an 
open bulging fontanel, an amount can be withdrawn which will 
appreciabl}' depress the fontanel. Dry taps, which occasionally 
occur, are usually the result of imperfect technic, the operator either 
not reaching the spinal canal, or the needle becomes obstructed 
with blood. If the exudative processes have occluded the connection 
between the ventricles of the brain and the cerebral and spinal sub- 
arachnoid spaces, as sometimes occurs in well-advanced cases, the open- 
ing may be partially occluded and the fluid flow very sparingly. In 
cerebrospinal meningitis the fluid obtained is generally clouded or 
turbid, sometimes it is purulent or again varies from time to time. 
In a small percentage of cases it is quite clear throughout. It contains 
the diplococcus intracellularis, and in some aspirated fluids in addition, 
staphylococci and streptococci are found. Poljmuclear leukocytes 
predominate and contain the specific organisms. 

Complications. — Those which may be attributed more directly 
to the disease itself are those of the eye, the ear, the brain, and the joints. 
The drum frequently is infected and may result. in deafness and the 
labyrinth is apt to be likewise involved. 

Chronic hydrocephalus develops in a number of cases beginning 
either during the acute stage or in convalescence. They are usually 
mentally deficient or idiotic. 

Rarely an arthritis develops in one or more joints. 

Differential Diagnosis. — As a rule, the symptoms are typical enough 
to make the diagnosis of meningitis, which is confirmed and further 
differentiated by lumbar puncture. The sudden onset, the headache, 
fever, vomiting, or convulsions in the face of an epidemic are especially 
significant. Meningitic symptoms in typhoid fever with rapid onset 
are often confusing. The blood examination for leukocytosis and the 
Widal reaction should be used to assist in the differentiation. Tuber- 
culous meningitis, especially in infancy, is often confused with spo- 
radic cases of cerebrospinal meningitis, and indeed the pathological 
examination of the spinal fluid may in some cases be absolutely necessary 
to differentiate them. The slow onset in tuberculous meningitis, the 
low leukocyte count, and the absence of hyperesthesia' are distinctly 
helpful points. 

Prognosis. — We can base our prognosis on the following facts: 
Sporadic cases have a greater natural tendency to recovery. Initial 
symptoms do not, as a rule, indicate the subsequent course. Mixed 



316. DISEASES OF CHILDREN. 

infections as found in the spinal fluid indicate a general septic condi- 
tion and an unfavorable prognosis. The younger the patient the 
more unfavorable the outcome. Do not interpret as a sign of restora- 
tion to health a temporary remission with return of consciousness 
from coma. 

Widely dilated, rigid pupils, unvarying coma with slow pulse, sub- 
normal temperature, persistent opisthotonos, and convulsions are signs 
tending to a fatal termination. 

Treatment. — The germ and its toxins must be combated. De- 
tailed study of the portals of entry of the infecting organism has thus 
far failed to establish much that is new. Care of the nasopharynx 
as insisted upon by Jacobi and Caille is a local measure productive of 
much good, especially in the crowded centers. School inspection and 
a higher standard of sanitary regulations in every district will do much 
to prevent epidemics of this disease. 

Serum Treatment. — The promising results that have been obtained 
from the use of Flexner's antimeningitis serum when used by the sub- 
dural method warrant its use in cases in which the diplococcus intra- 
cellularis has been demonstrated. If the bacteriological test is 
impracticable or would be unduly delayed, the serum injection is 
advisable in those cases in which a cloudy fluid is withdrawn by lumbar 
puncture. The earlier the serum is injected the better the results. 
By its use this long exhausting disease appears sometimes to be 
shortened and serious complications prevented. The serum is injected 
through the same needle after the withdrawal of at least 30 c.c. of spinal 
fluid. The serum is obtained in vials containing 15 c.c. each, and two 
of these vials warmed to body heat are slowly injected into the canal 
unless undue resistance contraindicates. The injections are repeated 
daily from four to six days, during which time smear preparations will 
give information as to the effect on the diplococci. If the temperature 
drops and the coma is lessened, the intervals are increased and the 
injections are repeated only when any aggravated symptoms return. 
In infants sometimes not more than 15 to 20 c.c. of serum can be in- 
jected, without producing pressure. In older children, on the other 
hand, when the pressure symptoms are intense and the fluid flows 
freely, as much fluid as possible should be allowed to escape and a cor- 
responding amount of serum injected. The New York Board of Health 
and Mulford & Co. are now manufacturing this serum. 

General Treatment. — A very important element of the treatment 
is conservation of the patient's strength by well-regulated nourishment 
and skillful, nursing. Care of the excretory functions and relief of 
pressure symptoms are important elements of the treatment. The 
patient should be isolated in a well-ventilated quiet room, the eyes 



THE INFECTIOUS DISEASES. 317 

shielded from the hght, the head and the neck being raised upon a 
pillow to relieve in part the congestion of the brain. The bowels 
are kept open by calomel or enemas. The diet may be fluid or semi- 
fluid, of a stated quantity, and careful note kept of the amount in- 
gested. Forced feeding should be resorted to if necessary by gavage. 
Water should be given freely. An ice-bag should be applied inter-- 
mittently to the head if the temperature rises above 101° to 102° F. 
Warm baths at 115° F. for twenty minutes, twice a day, with cold 
applications to the head, do much to produce comfort and allay pain. 
While in the bath the nasopharyngeal toilet can be made with normal 
saline solution. Colonic irrigations are used to eliminate the toxins, 
promote the flow of urine, and to stimulate the patient. When they 
are given at a temperature of 80° F. they also control the higher rises 
of temperature. 

The baths will also prevent in great measure the formation of 
bed-sores, and the necessary change of position will be beneficial to 
the pulmonary circulation. 

For the relief of marked restlessness or convulsions bromids 
and chloral per rectum are to be preferred to the opiates. Camphor 
in sterile olive oil hypodermatically (one grain to ten minims) is 
given when stimulation is necessary. 

Lumbar Puncture: This procedure will be indicated for (a) 
purposes of diagnosis; (b) in infants where there is a bulging fontanel 
or in children where Macewen's sign can be elicited, and in any case 
to control convulsions or sudden onset of coma; in other words, symp- 
toms of intracranial pressure, and (c) for the injection of the anti- 
meningitic serum. 

Anterior Poliomyelitis. 

(Infantile Paralysis. Essential Paralysis of Children. 
Acute Atrophic or Wasting Paralysis.) 

Definition. — An acute inflammatory process taking place in the 
anterior horns of the spinal cord, accompanied by a sudden and com- 
plete paralysis of various groups of voluntary muscles, followed b}^ a 
rapid wasting of the affected muscles. 

Etiology. — The onset, course, and symptoms suggest an infectious 
nature, but no microorganism as a cause of the disease has yet been 
discovered.* The nerve centers of the brain and spinal cord, the fluid 
derived from lumbar puncture, and the blood have as yet been searched 
in vain for the specific cause. Special liability to the disease exists 
below the age of three years, fully half of the cases occurring during 

* Flexner and Lewis have discovered that the virus may be situated in the naso-pharyngeal 
mucosa of monkeys. Osgood and Lewis found in several cases that the virus remained infective 
tor several months. 



318 DISEASES OF CHILDREN. 

this period. This is Ukewise the period of dentition, but it is doubtful 
if this bears any causative relation to the disease. Cases occur often- 
est in warm weather and boys are attacked oftener than girls. Oc- 
casionally the disease comes on after exposure to cold; it may also be 
seen in connection with certain infectious fevers, such as scarlatina 
and typhoid fever. The relation between these factors and the 
disease, as to cause and effect, is somewhat uncertain. The occurrence 
of occasional epidemics confirms the theory of the probable specific 
infectious nature of the disease. 

Pathology. — The inflammation that is localized in the anterior 
horns of the spinal cord seems to be induced by some toxin brought 
there by the blood current. There is dilatation and proliferation 
of the endothelial walls of the blood-vessels of the part of the cord 
affected. The central arteries of the spinal cord are intensely con- 
gested followed by those of the anterior median fissure. As the 
posterior horns are chiefly supplied ♦.with blood from the peripheral 
arteries, they are less affected when the inflammation is limited to the 
distribution of the central arteries. After engorgement of all the 
arterial twigs, diapedesis occurs and infiltration of the tissue by small 
cells and serum. According to Goldschreider, it is this choking of the 
gray matter by the inflammatory products that leads to the suspension 
of functional activity, and when, as in many cases, from impoverished 
nutrition the cells of the anterior horns are actually disintegrated by 
the inflammatory products, permanent destruction of the nerve tissue 
ensues. The ganglion cells soon show granular degeneration which 
may be followed by disintegration and atrophy. The cells in the 
anterior horns are arranged in groups having definite physiological 
motor and trophic functions. When these cell groups are finally 
destroyed and replaced by connective tissue, the parts they innervate 
will likewise undergo degenerative changes. The muscles become 
atrophied, and their fibrils replaced by connective or adipose tissue. 

Symptomatology. — The invasion is usually acute with evidences 
of general infection. There may.be gastroenteric or nervous dis- 
turbances with fever. The disease often begins with vomiting, and 
diarrhea may occasionally ensue. In other cases, general convulsions 
are seen at the beginning. Very rarely stupor or coma may follow 
the convulsions and last for a day or so. The temperature is frequently 
high at first, perhaps reaching 104° or 105° F.; in other cases it is 
slight — not more than 100° or 101° F. In rare instances the initial 
symptoms may be so mild as to escape attention and the paralysis is 
the first thing noted. In the majority of cases, however, some initial 
symptoms, more or less marked, will last from one to four days before 



THE INFECTIOUS DISEASES. 



319 



paralysis is discovered. Occasionally pains in the limbs may precede 
and accompany the paralysis for a time, and thus simulate periph- 
eral neuritis, but such pains do not last long. The most obscure cases 
are those in which the child is suddenly found to be unable to stand 
or walk, perhaps after being taken out of bed in the morning. The 
paralysis is absolute, the affected part being completely flaccid. It 
develops rapidly, usually reaching its full extent in from twenty-four 
to forty-eight hours; in rare cases it may be slower in onset, so that a 

week or even longer may elapse before 
it appears to reach its maximum extent. 
There is then a more or less rapid sub- 
sidence of the loss of power, but little 
change is to be noted during the first 
three or four weeks after the beginning 
of the attack. Most of the improve- 
ment will take place during the first 
three months, and after this interval 
any paralysis remaining will usually be 
permanent. The paralysis most often 
takes the form of monoplegia, the right 
leg being oftenest affected. The left 
leg and the right or left arm may be- 
come involved with a frequency usually 
in the order named. In severe cases 
all four extremities may be involved 
and even the muscles of the back and 
neck so that the child cannot sit erect 
or hold its head up. In very rare in- 
stances the medulla and base of the 
brain may be attacked, as well as the 
anterior horns of the cord, forming the disease called by Striimpell 
polioencephalitis. The cranial nerves may then become affected and 
the patient shows signs of bulbar paralysis as well. These severer 
types are more apt to be seen when the disease is epidehiic. In other 
rare instances there may be hemiplegia simulating cerebral paralysis. 
Paraplegia is rare. Many cases will only show a paralysis involving 
one group of muscles, as the peroneal type. As the motor cells in the 
anterior horns are arranged in groups, the muscles involved will be 
found to have a coordinated physiological function. The limb affected 
is apt to be cooler than the other parts, and an atrophy soon affects the 
paralyzed muscles. The wasting may be noticed within a week or two, 
and at two or three months becomes very marked. Eventually 




Fig 85. — Foot-drop in anterior 
poliomyelitis. 



320 



DISEASES OF CHILDREN. 



various deformities result as the growth of bone is arrested and the 
whole limb becomes smaller. Where only one or two groups of mus- 
cles are affected by atrophy, the opposing healthy muscles will pro- 
duce other deformities. In old cases, where a whole limb has been 
affected, there will be various grades of subluxation from a relaxation 
of the muscles and ligaments around the joints. The knee and shoul- 
der are particularly apt to be involved in this way. The electrical 
reaction of muscles and nerves may prove helpful in recognizing the 
disease. While the galvanic and faradic responses may be increased in 
the first two days, there is soon a loss of response to the faradic current 
with a reaction of degeneration to the galvanic current shown by the 
anodal closure contraction being greater than the cathodal elosure 
contraction. If the part affected responds to faradism within a few 
weeks it will probably not be permanently paralyzed. 

The reflexes are lost in the affected muscles. The commonest 
example of this is seen in loss of the knee-jerk. Complete recovery 
of all the muscles affected is extremely rare, although the permanent 
paralysis may be limited to only one or two groups of muscles. In 
very rare cases death may take place during the early course of the 
disease. The writer has known this to occur only in the epidemic form. 

Diagnosis. — It is impossible to make a positive diagnosis before 
the onset of the paralysis as the first symptoms resemble those of other 
acute infections. However, an absolute paralysis preceded by 
vomiting, fever or convulsions points to a spinal origin. In a few 
cases there may be early cerebral symptoms simulating cerebro- 
spinal meningitis, but paralysis comes later, if at all, in the latter dis- 
ease, and the stiff retracted head comes early. On lumbar puncture 
the fluid is usually found to be under pressure, but clear or opalescent. 
The cytological characters of a cerebrospinal meningitis are absent. 
It is not always easy to differentiate a palsy as cerebral, spinal or per- 
ipheral. The following points may be considered as helpful: 



I 



Cerebral 
(or motor projection fibers in 
spinal tracts) 


Spinal 
(gray matter) 


Peripheral 
(nerves) 


Onset sudden, with convul- 
sions. 

Usually affects entire limb 
and incomplete. Paresis. 

Hemiplegia (rule) 


Onset sudden, with fever 

Affect muscular groups 
having coordinated 
functions and not sup- 
plied by simply one 
nerve. Total paraly- 
sis (rule). 

Monoplegia (rule) leg . 
Hemiplegia (rare) . . . 
Paraplegia (rare) . . . 


Onset gradual (1 to 4 
weeks) . 

Affects muscles supplied 
by one nerve. Total 
paralysis (rule). 

Paralysis symmetrical. 
Paraplegia the rule. 
Upper, lower, or all 
four extremities. 


Monoplegia (rare) arm 

Paraplegia (very rare) 



THE INFECTIOUS DISEASES. 



321 



Cerebral 

(or motor projection fibers in 

spinal tracts) 



Spinal 
(gray matter) 



Peripheral 
(nerves) 



Muscles stiff or riarid. 



Sensory disturbance usually 
absent. If present, par- 
tial anesthesia 



Muscles flaccid. 



No atrophy, or late from dis- 
use. 

Deformity early. Athetosis. 



Growth of part not much im- 
paired. 

Temperature of part little 
affected. 



Increase of all reflexes 

No reaction of degeneration. 



Mind often affected. Weak- 
ness or epilepsy. 



Sensation not affected; 
sometimes, but rarely 
general pains very 
early in disease. 



Early and rapid atrophy 
Deformity late 



Muscles flaccid. 

Association of sensory 
with motor paralysis. 
Numbness, tingling, 
sensations of heat or 
cold. Limb usually 
painful along course 
of nerves affected. 

Atrophy rapid. 

Permanent contractures 
rare. 



Growth much impaired. Growth not impaired. 



Some coolness in affect- Slight coolness of mus- 
cles affected. 



ed limb. 
Loss of reflexes 



Always reaction of de- 
generation. 



Loss of reflexes. 

Usually reaction of de- 
generation. 



Mind clear and no men- Mind clear and no men- 
tal sequelse. tal sequelae. 



Prognosis. — A more or less rapid lessening in the extent of the 
paralysis nearly always occurs during the first few weeks after the 
beginning of the attack. There will be little or no improvement 
after the third or fourth month. The prognosis for muscles that 
waste rapidly is poor. A reaction to the faradic current is a sign 
of beginning improvement. After a year the condition will be 
absolutely stationary as far as the paralysis and trophic disturbances 
are concerned. Complete recovery is exceedingly rare, and is more apt 
to be seen in the epidemic form. In some cases, however, so few 
muscles are permanently paralyzed as to simulate entire recovery. 
The prognosis for life is exceedingly good, although a few will occa- 
sionally die early in the attack in epidemics of the disease with symp- 
toms of severe infection. As there is no involvement of the brain, 
the mind will not be in any way affected, and there are no late sequelae 
such as epilepsy. 

Treatment. — If seen early, and the temperature is high, ice-bags 
may be applied to the spine. When this is discontinued, stimulating 
embrocations may be applied, such as one part of turpentine in two 



322 DISEASES OF CHILDREN. 

parts of camphorated oil, sprinkled over a strip of flannel. The 
bowels should be kept open and a mild, unstimulating diet given. 
Any irritability of the nervous system may be controlled by bromid 
of sodium — from three to five grains, every three or four hours. 
During the stage of active congestion, in the first two weeks, from five 
to ten minims of fluid extract of ergot every four hours is supposed 
by many to have some effect in diminishing spinal congestion. Abso- 
lute rest, in an easy, recumbent position is very important during the 
first few weeks. No effort must then be made to stimulate the 
paralyzed muscles, and the parts must, if necessary, be kept in a 
natural position by straps or orthopedic apparatus to prevent early 
deformity by contractures. It is especially necessary in the case of 
drop-feet to raise and support these parts, after the symptoms of 
central nerve irritation have passed — usually in about three weeks; 
strychnin, massage, and electricity may be employed. If the muscles 
do not respond to the faradic current, galvanism may be employed. 
The late deformities of the disease come before the orthopedic surgeon 
for attempted correction. Tenotomy, various braces, and induced 
anchylosis for the "flail-joints" may all be required. 

Epidemic Paralysis in Children. 

The occurrence of epidemics of paralysis in children has been 
reported in recent years by a number of observers. They have 
generally been considered as cases of anterior poliomyelitis, and have 
natural y provoked renewed discussion as to the essential cause of 
this disease. The prevailing idea among recent writers appears to be 
that the spinal paralysis of children is an infectious disease, and 
occasional epidemics confirm this view. The abrupt onset, the fever, 
the gastric disturbance, occasional attacks of convulsions seen both 
in the epidemic and endemic forms of the disease point to its infectious 
nature. In the epidemic form, a considerable variation from the 
usual type of the disease has been noticed, some cases presenting the 
symptom-complex of Landry's paralysis, the infectious nature of 
which is known. It must be borne in mind, however, that while the 
microbic nature of poliomyelitis may thus by analogy be assumed, it 
has not yet been scientifically demonstrated. Medin reported an 
epidemic during the summer of 1887 in Stockholm with some fatal 
cases. In this country Dr. Caverly has reported an epidemic occurring 
in the summer of 1894 in Rutland, Vermont. One hundred and thirty- 
two cases were reported, occurring oftenest in strong, healthy chil- 
dren. Many of the cases showed marked hyperesthesia of the skin 

* Recent research work would indicate that mild antiseptic lotions applied to the naso-pharynx, 
may be valuable for prophylaxis, Uro tropin in fairly large doses may be administered as a pre- 
ventative during epidemics as well as during the course of the disease. 



THE INFECTIOUS DISEASES. 323 

and others exhibited muscular rigidity of ihe neck or back. Eigh- 
teen of the cases were fatal, usually dying early in the attack. A 
curious feature of this epidemic was that domestic animals were 
affected by the disease. Horses, dogs, and fowls became paralyzed, 
and an autopsy on a horse and fowl showed the lesions of polio- 
myelitis. This epidemic occurred in a very dry season, and the same 
thing has been noted in most other epidemics. 

An interesting epidemic, reported by Dr. Chapin, occurred during 
the summer of 1889, at Poughkeepsie, N. Y., most of the cases being 
attacked between the middle of July and the middle of August. A 
peculiarity of this epidemic appeared to be the existence of severe 
pain in the parts affected by the paralysis. A number of the cases 
carefully examined showed absolute paralysis of the limbs affected, 
with loss of reflexes and apparently considerable pain on handling 
the part. There was such marked evidence of the action of some 
infectious principle that examinations of the blood from ihree cases 
were made by Dr. H. T. Brooks. These failed to give any positive 
results, although the specimens did show occasional minute micro- 
organisms (a diplococcus) to which, however, no etiological significance 
was attached because of the small number of specimens and also 
because the latter may have been contaminated from the skin or other 
source. 

The prominent feature of pain and its more or less persistence in 
the affected limbs, brought up the question of neuritis. One of the 
cases proving fatal, a careful autopsy was made, and the nature of the 
disease in this particular case was proven to be poliomyelitis. It 
seemed that while this epidemic was apparently of an infectious nature, 
in some cases the infecting principle attacked the anterior horn of the 
spinal cord, in others the peripheral nerves, and that possibly, in a 
few cases, both parts were attacked. Some of the cases were reported 
by the physicians in attendance to have made complete recoveries 
in from one to four months. In both the Stockholm and Rutland 
epidemics, polioneuritis was reported to exist in some of the cases with 
poliomyelitis. 

During the summer of 1907 an epidemic of considerable propor- 
tion existed in New York and the surrounding country. In this 
epidemic, pain in the extremities formed a marked feature, and in some 
cases marked cerebral symptoms were noted. Many of the cases 
showed great gastroenteric irritation at the onset of the disease. 
Occasionally headache and rigidity of the neck simulated cerebro- 
spinal meningitis. A few cases were reported in which symptoms of 
bulbar involvement occurred. A number of deaths were also reported 



324 DISEASES OF CHILDREN. 

during this epidemic, the fatahties occurring early in the disease. 
[t is beheved that the following points will fairly represent the peculiar- 
ities of the epidemic form of paralysis in children: 

1. The disease is occasionally fatal, especially early in the attack. 
The endemic form is rarely, if ever, fatal in its ending. 

2. There are great variations in the extent of the paralysis in 
the epidemic form. Many cases show very extensive palsy, involving 
all the extremities and the muscles of the back and neck as well. 
Other cases show a very slight loss of power, and the disease is doubt- 
less occasionally overlooked from this cause. 

3. Pain seems to occupy a more prominent feature in the epidemic 
than in the endemic form. This pain may even last well along in the 
course of the disease. In the ordinary endemic disease if pain exists, 
it is not apt to last more than a day or so. 

4. A certain proportion of cases in these epidemics seem to un- 
dergo a complete recovery. This rarely, if ever, happens in the 
endemic form. 

5. The lesion tends to be more varied and extensive in the epi- 
demic than in the endemic form. It may include the following con- 
ditions: Polioencephalitis of Striimpell; poliomyelitis; peripheral 
neuritis, and occasionally meningitis. 

Acute Articular Rheumatism. 

{Rheumatic Fever.) 

Acute articular rheumatism is a febrile disease of the joints 
characterized by transitory inflammatory attacks which do not tend 
to suppuration. 

Etiology. — The infectious origin of the disease is accepted as a 
fact; although the direct etiological factor is still in dispute. The 
disease assumes certain characteristics in childhood which distinguish 
it from the adult type. The course is milder and shorter, while involve- 
ment of the heart is more frequent than in adults. 

Single epidemics and a succession of epidemics have been reported 
from time to time. Several members of the same family may be 
attacked simultaneously. 

The oral cavity and more particularly the tonsils have been re- 
garded by many as the portal of entry of the infecting organism. 
Predisposing factors are exposure and residence in cold damp apart- 
ments, Heredity seems to play a distinct part if the predisposing 
factors are present. 

The disease is not very common before the fifth year, although 



THE INFECTIOUS DISEASES. 325 

cases have been recorded during the nursing period. One attack pre- 
disposes to subsequent attacks. 

Among the 76 cases studied cHnically by Chapin the following 
were the ages : 



6 mos. 


, 1 


9 yrs., 


9 


11 mos. 


,1 


10 yrs., 


5 


20 mos. 


1 


11 yrs., 


8 


3 yrs., 


1 


12 yrs.. 


7 


4 yrs., 


2 


13 yrs., 


9 


5 yrs., 


4 


14 yrs. 


4 


6 yrs.. 


6 


15 yrs. 


,2 


7 yrs., 


3 


17 yrs. 


,2 



8 yrs., 11 

Symptomatology. — An attack may be preceded by languor, loss of 
appetite, mild tonsillitis, abdominal pains, and indefinite pains in the 
joints. With the localized pain theie is a febrile reaction of variable 
intensity, 102-104° F., and occasionally there is vomiting. The knee- 
and ankle-joints are, as in adults, most frequently involved. In chil- 
dren the hip and cervical vertebrae and joints of the fingers and toes may 
be the areas attacked. Usually more than one joint is affected, but 
symmetrical involvement is not the rule. It is exceptional for the 
attack to persist more than a few days in any one joint. The joints, 
as a rule, are not exquisitely painful on active or passive motion, while 
the swelling, if any, is moderate. The fascia covering muscles may be 
attacked without any involvement of the joints. The sternocleido- 
mastoid muscle is especially liable to such attack. The acid perspira- 
tion so commonly observed in adults is rarely present in children. A 
waxy appearance is observed in severe cases Avith insomnia, anorexia, 
and insatiable thirst. 

The blood findings are of no assistance in making the diagnosis. 
Mild, almost afebrile cases may, however, be followed by serious in- 
volvement of the heart. 

Complications. — These bear a direct relation to the toxins of the 
disease itself. Rheumatism in childhood is characterized by its 
cardiac complications; it thus must always be considered as a dis- 
ease of serious import. Nearly half of all the cases leave permanent 
cardiac effects. 

The mitral valve is most frequently affected. The involvement 
is accompanied by irregular rises of temperature and increased pulse 
rate. The symptoms accompanying valvular defects, however, may 
be the first indication for medical attention and lead to the discovery of 



326 DISEASES OF CHILDREN. 

their rheumatic origin. Pericarditis is present in 10 to 20 per cent, 
of all cases in children and is frequently associated with endocarditis, 
and is an important and often fatal complication. Serous, or sero- 
fibrous pleurisy, is a complication seen in severe and long-standing 
cases. Pneumonia and occasionally nephritis are rarer complications, 
in all probability due to mixed infection. A purpuric rash or an 
erethema may be seen as rheumatic manifestations. Chorea must be 
regarded as a distinct rheumatic manifestation and often may precede 
the disease. Involvement of the endocardium is not rare in cases of 
chorea. Rheumatic iritis is rare in childhood, but can be diagnosti- 
cated by a competent opthalmologist. 

Rheumatic nodules occasionally appear under the skin developing 
rapidly. They appear, as a rule, near the joints, and follow the course 
of the tendons. Sometimes they are painful on pressure. They 
may be from one to fifty in number, and may last for several weeks 
before absorption takes place. 

Prognosis. — Rheumatic polyarthritis in children tends to quick 
recovery. Relapses are common, and it is in these secondary attacks 
that the endocardium most often suffers. Fatalities may follow severe 
complications. 

Differential Diagnosis. — Septic arthritis as seen in scarlet fever 
and gonorrheal arthritis should be excluded, as should the rarer cases 
of pneumococcic arthritis. The history and the intense localization 
tending toward suppuration in the septic types will assist in making the 
diagnosis. A blood count in septic cases will show high leukocytosis. 
An exploratory puncture is often justifiable in establishing a prompt 
diagnosis. 

Scarlatinal poly art hritides, as a rule, affect the wrist-joints first, 
then the shoulders, knees, and feet. They appear in the second or 
third week of the disease, and last about one week unless suppuration 
sets in. 

Pneumococcic arthritis is seen usually in the first and second 
years of life as a sequel of a bronchopneumonia, or a lobar pneumonia. 
The pus contains diplococci which stain by the Gram method. As 
a rule the affection is limited to one joint. 

Gonorrheal arthritis is rare in children, although often decidedly 
puzzling from a diagnostic standpoint, unless evidences of a previous 
gonorrheal infection are obtained. It appears some weeks following 
the local attack. The knee-joints are, as a rule, primarily involved, 
but in- children it is very apt to be polyarticular. The articulations 
are extremely painful, there is a high irregular temperature and the 
effusion in the joints contains typical gonococcL 



THE INFECTIOUS DISEASES. 



327 



Syphilitic arthritis is symmetrical, and other evidences of the dis- 
ease may be present. 

Cases of epidemic poliomyelitis which complain of intense pain 
have been mistaken for rheumatism. The loss of the patellar reflexes 
and the electrical reaction will serve to distinguish them. 

' Scurvy in infancy may occa- 

sionally be mistaken for rheumatic 
polyarthritis. The history, exami- 
nation of the gums, of the urine, the 
localization, and the X-rays will 
prevent a mistake in diagnosis. 

Treatment. Prophylactic. — 
Children predisposed to rheumatic 
fever or who have had an attack 
of rheumatic fever or chorea should 
avoid exposure to dampness or 
cold. The tonsils, if hypertrophied, 
should be removed. The diet must 
be carefully regulated and all forms 
of intestinal fermentation promptly 
treated. 

Management. — Rest in bed 
should be considered as the first 
and most important direction, and 
the patient should be kept in bed 
until all rheumatic manifestations 
have ceased. Wearing of woolen 
or merino undergarments is to be 
recommended. 

The diet may consist of milk, 

broths, paps, bread, and lemonade 

for the thirst. When the fever has 

passed, vegetables, eggs, and finally 

meats are allowed. 

Drugs. — The salicylates in the form of the sodium salts or, better 

still, novaspirin are effective remedies to control the attacks. Rest 

in bed and the early exhibition of the salicylates are the only weapons 

against the cardiac complications. 

Novaspirin in doses of 2 to 5 grains three to four times daily 
to a five-year-old child should be persisted in for a week or more. 

Salol, aspirin, phenacetin, salipirin, and salophen (see Dosage, 
page 80) may be substituted if the above remedies are not effective. 




Fig, 86. — Gonorrheal arthritis, com- 
phcating gonorrheal vulvo-vaginitis 
Polyarticular in distribution. 



328 



DISEASES OF CHILDREN. 



The tincture of the chlorid of iron, five drops in water after meals 
in convalescence is beneficial. However, if the diagnosis be correct, 
aspirin or sodium salicylate will give speedy relief. The joints should 
be enveloped in cotton wool. ImmobiUzation with splints, especially 
with restless children, will often give considerable relief. An ice-bag 
is appHed over the heart for an unduly rapid pulse or endocardial 
involvement. 




Fig. 87. — Infectious arthritis. {Dk MacKenzie's case.) 



Infectious Arthritides. 

Following any of the acute infectious diseases, especially pneu- 
monia, scarlatina and typhoid fever, there may result an active 
inflammation in the joints or neighboring bony structures. These 
arthritides result from bacterial invasion in some instances, and in 
others are apparently the result of the toxic products of the under- 
lying disease. Suppuration may occur, as evidenced by fluctuation 
and tenderness. Aspiration is then indicated and, besides relieving 
the joint, assists in establishing the diagnosis from a bacteriological 
standpoint. These cases do not react to the sahcylates or their 



THE INFECTIOUS DISEASES. 



329 



derivatives, and are to be distinguished by the greater degree and 
rapidity of the involvement and the tendency to suppuration. The 
temperature often assumes the wide variations seen in sepsis of any 
part of the body. 

Rheumatoids. 



Formerly these affections were classed under the head of chronic 
articular rheumatism, and much confusion has resulted from attempts 

to classify them as following or 
developing from rheumatic fever. 
One group of these cases 
often designated as villous ar- 
thritis results from thickening of 
the synovial sheath and an over- 
growth of the viUi within the 
joint. This affection may be 
mono- or polyarticular, and 
spreads, if at all, only slowly 
from joint to joint. As a rule, 
there is no fever, the joints 
assuming a swollen, waxy, shin- 
ing appearance. In cases of 
long standing the joints become 
more or less ankylosed and 
deformities result. 

Aethritis deformans 
sometimes occurs before puberty , 
but it is rare. The characteristic 
features are joint deformity, 
pain, and disability. The 
disease affects many joints at 
one time and progressively in- 
volves others. The joints of the fingers are, as a rule, the first to 
be affected. Later there is seen much atrophy of the soft parts 
and even of the bones themselves. These chronic forms must be 
differentiated from tuberculous and syphilitic arthritides. Syphihtic 
affections usually appear late in neglected cases and fortunately are 
rarely seen in children. There is an effusion of serofibrinous fluid 
into the joint accompanied by little or no constitutional symptoms. 
The history, and sometimes a specific inflammation of the cornea may 
definitely determine the diagnosis. 




Fig. 88.- 



- Arthritis deformans in an eight- 
year-old girl. 



330 DISEASES OF CHILDREN. 

Tuberculous arthritis is accompanied by bone changes and 
the X-ray should be employed to clear up a case that offers any 
difficulties in diagnosis. The tuberculin reaction, inoculation experi- 
ments in animals, or the tuberculin tests, cutaneous, percutaneous, 
and into the ocular conjunctiva, may also be employed as diagnostic 
aids. 

Treatment. — In the early stages, if there is any pain, rest in splints 
will afford much relief. As pointed out by Taylor, the diet should 
be nutritious and not restricted. Later massage and careful passive 
movements combined with baths sometimes lead to success. Ortho- 
pedic appliances and surgical intervention are often necessary to 
correct resulting deformities. 

Still's Disease. — This is a polyarthritis occurring in childhood 
which is as yet little understood. Clinically, it seems related to certain 
forms of chronic sepsis or tuberculosis. 

There develops an enlargement and partial ankylosis of the joint 
with some temperature of an irregular type associated with splenic 
hypertrophy, and quite general enlargement of the liver and lymphatic 
glands. 

As distinguished from the other rheumatoids, the disease does 
not tend to destructive changes in the joints, and in fact seems to be 
self-limited. Following the suggestion of Nathan, thymus extract in 
five- to twenty-grain doses three times a day may be given. 

Malaria. 

(Paludism.) 

Malaria is an infectious disease caused by the hemacytozoon of 
Laveran, and characterized by a periodic intermittent or remittent 
fever. 

Etiology. — The parasite is carried through the anopheles mosquito 
which is distinguished from the common mosquito or culex by the 
following characteristics (see Fig. 89): 

Anopheles. Culex. 

1. Two large palpi on side of 1. Small palpi. 

proboscis. 

2. Mottled wings. 2. No spots on wings. 

3. Body held at an angle 45° 3. Body held parallel. 

or more. Posterior legs often crossed 

over back. 

4. More often found in the 4. More often found in cities. 

country. 



THE INFECTIOUS DISEASES. 



331 



The parasite of Laveran occurs in three forms: the tertian, 
quartan, and estivoautumnal. 

In the fall of the j^ear the greater number of cases are seen. 
Regions in which much marsh land is found are favorable places for 
the breeding of the anopheles, and in these localities malaria is natur- 
ally more prevalent. 




Fig. 89. — A, Anopheles claviger; B, Specimen of culex; C, Different 
positions assumed by Anopheles and Culex when at rest. 



Pathology. — The tertian variety develops in the human organism 
in forty-eight hours. At first there is seen a small ovoid particle 
within a red blood-celL Pigmentation appears as development pro- 
gresses around the periphery of the parasite. Ameboid movements 
may be noted. The hemoglobin of the red cell appears to be destroyed 
by the parasite. Segmentation now takes place, creating the spores 
which are freed in the blood stream and are ready to attack new red 
cells, and then pass through a similar cycle of development. 



332 DISEASES OF CHILDREN. 

The quartan type completes its development in seventy-two 
hours, producing the characteristic paroxysms on the fourth day, in- 
stead of on the third as in the tertian type. 

It may be differentiated from the tertian by the lack of move- 
ment on the third day, and by the peculiar yellowish-green color of the 
cell, and by the rosette appearance on the fourth day. 

The estivoautumnal variety takes twenty-four to forty-eight 
hours to complete its cycle, and cresentic forms appear after a week of 
development. The parasite is sparsely pigmented and smaller in size. 
The gametocytes or sexually differentiated types develop only in the 
intermediate host. Sporozoids develop in the host or mosquito, and 
through its salivary glands infect, the bitten individual where they 
develop into parasites and pass through one of the cycles as just 
described. 

In mild cases of malaria little alteration in the body structures 
may be found besides an enlarged spleen and changes in the blood. 
Malaria is rarely fatal in infants and children. 

In the pernicious forms both the liver and spleen are enlarged. 
In chronic malaria the spleen and sometimes the liver become hard 
and deeply pigmented. 

Symptomatology. — In infants (in whom it is quite rare) and in 
younger children the symptoms are irregular in form and the diagnosis 
often obscure. In older children the typical adult type is seen, pre- 
senting rttle or no difficulty in diagnosis. A distinct chill or chilly sen- 
sations and sometimes a convulsion may usher in an attack. 

The child has been listless for several days or complains of being 
tired, stretches, and yawns. The extremities are cold, and the cjiild 
seeks its bed for warmth. 

The common type in infants and younger children results from 
a double infection with the tertian parasite, producing the so-called 
quotidian fever. The temperature is high with a corresponding pulse 
rate. 

The estivoautumnal type is not often met with; it produces a 
very irregular form of fever with or without a definite paroxysm. 
The fever may be intermittent or even remittent in type; that 
is, a contnuous fever with small excursions and no drop to the 
normal. 

In older children, as has been said above, the adult type is 
simulated. The period of chill is followed by the stage of fever and 
more or less perspiration. The temperature reaches 104° or 105° F. and 
is accompanied by headache, often vomiting and extreme thirst. 
A normal or subnormal temperature follows after the period of high 



THE INFECTIOUS DISEASES. 333 

fever. The succeeding day a robust child may be willing to go about 
and play as usual. 

In the cities we see a subacute variety, usually in children, about 
the fifth year of age. They are brought because they are on differ- 
ent days listless, pale, and without ambition. The physical examina- 
tion often shows an enlarged spleen and characteristic blood changes. 
True chills are not experienced nor does one obtain a history of fever 
followed by perspiration. 

Malarial cachexia and the pernicious forms of malaria are rarely 
seen among children in the United States, at least in the North. In 
the cachectic or chronic type, the spleen is uniformly large and firm, 
sometimes extending to the crest of the ilium. In these cases the liver 
is apt to be enlarged. The child is extremely anemic, has a greenish- 
yellow tinge, and a poor complexion. Loss of appetite and constipation 
are commonly found. The urine is highly colored and may contain 
casts and blood. 

Differential Diagnosis. — Malaria must be differentiated from 
typhoid, secondary anemia, Banti's disease, and certain forms of neph- 
ritis. Repeated examinations of a fresh or stained specimen of blood, 
or both, should be made for evidences of the malarial organism. 

The therapeutic test with quinin may be made in suspected cases 
in which a blood examination is not feasible. 

The uniformly enlarged spleen found in malaria is a diagnostic 
feature of great importance. The spleen is said to be enlarged in a 
child when it can be felt. The Widal test and a differential blood 
count will often assist in fixing the diagnosis when a careful physical 
examination including the ears has been made to exclude other con- 
ditions. 

Treatment. Prophylactic. — The physician should be acquainted 
with the genus of mosquito in his locality. If the anoj^heles are present 
he should insist upon the authorities taking all possible measures to 
drain the swampy areas. The children's cribs should be closely 
screened. Water barrels and similar tanks must be protected by 
screens to prevent the development of larvae. The latter may be 
killed by the use of crude petroleum floated over infested pools. 

Therapeutic. — An initial purge with calomel is recommended. 
The early and continued use of quinin until a cure is effected is es- 
sential in any of the forms above mentioned. Relatively larger doses 
may be given to children than to adults. For infants and younger chil- 
dren, the soluble bisulphate is recommended. Its bitter taste is often 
less objected to by younger children than by their elders. The syrup 
of yerba santa best disguises its bitter taste if any addition is neces- 



334 DISEASES OF CHILDREN. 

sary. Euquinin and tannate of quinin are tasteless preparations 
which may be given in mild cases. The sulphate of quinin in half- 
grain doses may be made more palatable by the use of chocolate in 
tablets or lozenges. 

The year-old child may be given one grain of the sulphate or bi- 
sulphate every three hours. A child of five years, three grains every 
four hours. Larger doses may be given on well days, and decreased 
or omitted during the paroxysms. Where the stomach is irritable and 
the quinin not retained, rectal injections of the bisulphate may be 
made, preferably in a mucilaginous suspension. 

Suppositories of quinin are not very satisfactory for continued 
usage. The hydrochlorate or bimuriate of quinin in cocoa-butter 
should be used for this purpose. The hypodermatic administration 
of quinin in children in this country is unnecessary and uncalled for. 

The chill is combated with a number of hot-water bottles, a hot 
pack or a hot bath. The oncoming fever is allayed with alcohol spong- 
ing and cool drinks in small quantity at frequent intervals. 

Quinin should be administered for at least a week following the 
last symptoms of malaria. The elixir of iron, quinin and strychnia 
will do much to combat the resulting anemia, a half-dram three 
times a day after meals to a five-year-old child. Fowler's solution or 
Warburg's tincture are useful in the long-standing cases. 

Erysipelas. 

This is a constitutional infectious disease presenting a diffuse, 
rapidly spreading inflammation of the skin and subcutaneous con- 
nective tissue, and occasionally of the mucous membranes. 

Etiology. — No specific organism has been found in erysipelas, 
but a streptococcus is thought to be usually the active cause. It 
may occur in connection with a septic condition of the mother during 
or shortly after birth. The virus, enters the system through an 
abrasion of the skin or mucous membrane. 

Symptomatology. — The 'disease is more apt to occur during 
infancy than childhood, and the earlier it appears after birth the more 
serious will be its effects. In robust infants the inflamed skin will 
present a deep-red color, while in feebler babies it will be lighter, pre- 
senting more of a pinkish appearance. The deeper tissues may 
likewise be involved in a phlegmonous inflammation in severe cases, 
and there may also be edema and finally some desquamation. In the 
newly-born the disease is apt to be contracted from some septic 
condition of the mother. It may then start at the umbilicus, in the 



THE INFECTIOUS DISEASES. 



335 



genital region, or from some point of abrasion consequent to the 
delivery. Where the umbilicus is affected, the disease is apt to extend 
inward, producing a peritonitis. In other cases pneumonia or empy- 
ema may ensue and hasten the fatal ending. In older infants the 
disease begins on some abrasion of the skin, frequently around the 
genital organs, but sometimes on the trunk, arms, or legs. It is not so 
apt as in adults to attack the face and scalp. The cutaneous redness 




Fig. 90. — Erysipelas, which began on the face and spread over the body. 

and subcutaneous infiltration spread rapidl}^, but with a sharp line of 
demarcation between the diseased and healthy skin. The affected 
part is usually hot to the touch. The constitutional symptoms are 
commonly severe, with evidences of prostration. The result of the 
pricking or burning pain is seen in great restlessness, disturbed sleep, 
and occasionally convulsions. The fever is irregular and high where 
much of the skin is involved. The pulse is usually rapid and feeble. 
There may be evidence of gastroenteric irritation, shown either by 
vomiting or diarrhea. In fatal cases death usually results from 
exhaustion or from some complicating disease, such as peritonitis or 



336 DISEASES OF CHILDREN.. 

pneumonia. Abscesses and even sloughing of tissues may accompany 
severe and deep-seated erysipelas. The tendency to spread is shown 
in some cases by the whole surface of the body becoming involved. 
There is frequently in infants a recurrence of the inflammation 
involving the same surfaces as were originally attacked. The disease 
may last from one to three or four weeks. 

Prognosis. — The prognosis will vary with the age of the infant 
and the extent of the inflammation. It is very fatal during the first 
month, and from that period up to the sixth month the outlook will be 
uncertain. After six months the prognosis is good. Constitutional 
symptoms are usually less severe when the arms and legs are involved 
than when the disease affects the region around the umbilicus or the 
neck and head. If the inflammation is superficial and spreads slowly, 
the prognosis is naturally more favorable than when it spreads rapidly 
and is more deep-seated with the character of a cellulitis. 

Treatment. — While the disease cannot be aborted, every effort 
must be made to sustain the strength of the infant by simple, nourishing 
diet. If the mother is septic, the baby must be removed from the 
breast, but otherwise maternal feeding offers the best chance for 
recovery. In bottle babies it may be necessary to weaken the formula 
or to peptonize when there are evidences of digestive disturbances. 
We believe that tincture of the chlorid of iron is beneficial, and an 
infant of a year old may be given three or four drops, well diluted, every 
three hours. As it is an asthenic disease, it is often necessary to 
stimulate, giving 'strychnin or whisky when the pulse is weak. Many 
cooling and antiseptic applications have been tried upon the skin, 
but with doubtful results. Ichthyol, a dram to the ounce, may be 
employed to relieve itching and burning and act as a local antiseptic. 
Infants with erysipelas should be isolated, particularly when near 
surgical cases or those apt to have any abrasion of the skin or mucous 
membranes. Their clothing and bedding should be disinfected at 
the termination of the disease. 

The polyvalent streptococcic serum may be tried in desperate 
cases, but our experience with its use prevents its recommendation as 
a general remedial measure. 



CHAPTER XXIII. 
DISINFECTANTS AND DISINFECTION. 

Disinfection has for its object the limitation of an infective process 
already begun, the protection of those already exposed and the pre- 
vention of the spread of the infection to others. 

The disinfectants commonly used may be divided into two groups, 
the aerial and the chemical. 

Aerial. 

1. Formaldehyd. 

2. Superheated steam. 

3. Sulphurous acid (sulphur dioxid). 

4. Chlorin. 

Chemical. 

1. Mercurial salts. 

2. Carbolic acid. 

3. Calx chlorata (chlorid of lime). 

4. Formalin, etc. 

Formaldehyd gas is the best agent known at present for disinfec- 
tion of dwellings. If fairly concentrated, it kills bacilli and their 
spores. It acts rapidly, is less injurious in its effects on household 
goods, and is less toxic to the higher forms of animal life. 

To use formaldehyd, either of the following methods can be 
recommended. 

(a) Formaldehyd Generator. — A serviceable apparatus known as 
the Novy generator can be purchased for about four dollars. This 
consists of a copper boiler from which leads a tube; the latter is pushed 
into the keyhole of the door. About ten ounces of formalin solution (40 
per cent.) is added to a quart of water in the boiler and an alcohol 
lamp or "Primus" blast lamp placed underneath and the whole 
boiled. On boiling, formaldehyd gas is liberated and led into the 
room through the tube. One thousand cubic feet of room space can 
be disinfected with the above amount. 

(6) Method of Houghton and Clark. — Place 240 gm. of potassium 
permanganate in a three-gallon pail and put this in a tub or on a large 
zinc stove; add 480 c.c. formol to this. Violent ebullition and foam- 
22 337 



338 DISEASES OF CHILDREN. 

ing results and formaldehyd gas is liberated. This will disinfect 1,600 
cubic feet of space. The potassium permanganate can be mixed with 
15 per cent, of Portland cement and enough water to make the mix- 
ture of sufficient consistency to mould into bricks. The action in this 
form will be slower and less violent, although just as efficient. Place 
the formol (480 c.c.) in the pail and add three bricks made as above, 
each containing 80 gm. of potassium permanganate. 

(c) If paraform is used, 1,000 grams are required for every 1,000 
cubic feet of air space, the exposure lasting for at least six hours. 

Superheated steam is the most efficient measure for disinfec- 
tion known. Its use, however, is limited to institutions having an 
autoclave. 

Sulphurous acid results when sulphur is burned in air. Its potency 
is many times increased if the air is moist. When intensified in this 
way, this gas will destroy the non-sporing bacteria when in full con- 
tact. Spores are not killed even after long exposure. To fumi- 
gate by this method calk or seal the room .with adhesive-plaster strips 
and have a pan of water boiling in the room to provide moisture. It 
will be necessary to burn four pounds of sulphur per 1,000 cubic feet 
and allow an eight-hour exposure. • It is well to place the receptacle' 
containing the sulphur on a low iron tripod which stands in a large 
pan of water. Two or three ounces of alcohol poured over the sulphur 
before igniting it will insure good combustion. 

The objections to this method are: (a) a good exposure of infected 
surfaces is difficult to obtain as in books, mattresses, carpets, etc.; 
(b) spores are not destroyed; (c) wall paper, pictures, and colored 
hangings are bleached or discolored; (d) all metallic articles are 
blackened by the sulphide formed. 

Chlorin is formed when a strong mineral acid is mixed with 
chlorinated lime. Two pounds of the powder with an excess of the 
acid being used for 1,000 cubic feet of space. Chlorin is open to the 
same objections as the sulphur fumes when used as a disinfectant. 

Mercurial salts stand first among chemical disinfectants; the 
bichlorid, the biniodid, and the cyanid all being employed; of these, 
the bichlorid is the most potent and is most extensively employed. 
A solution of 1 to 1,000 will kill non-sporing bacteria in one minute 
and anthrax spores in ten minutes. Behring has shown that its effi- 
ciency is in inverse ratio to the amount of albuminous matter present 
in the material treated. With albuminous material, bichlorid forms 
an insoluable albuminate which prevents destruction of the inner 
portions. This feature makes bichlorid of mercury less suitable for 
use in disinfecting sputum, pus, or blood. 



DISIXFECTAXTS AXD DISINFECTION. 339 

Carbolic acid in a one to twenty or 5 per cent, solution will 
rapidly destroy non-sporing bacteria, although their spores are not 
destroyed for several weeks. Albumin, if jDresent, impairs its efficiency 
only slightly. Cresol, a derivative of carbolic acid, is also an excellent 
disinfectant. 

Calx chlorata (chlorid of lime) depends upon the formation of 
hypochlorous acid for its efficiency. The alkalinity of the lime 
present renders a solution of this agent most valuable for disinfect- 
ing albuminous material, as it first disintegrates and then disinfects. 
For practical purposes, no other chemical can compare with this agent 
for the disinfection of sputum and feces. If equal parts of a dilute 
solution of acetic acid (1.25 per cent.) or vinegar and a saturated solu- 
tion of chlorid of lime are mixed together this agent will destroy spores 
in one minute. Chlorid of lime rapidly deteriorates if left uncovered, 
due to liberation of the hypochlorous acid. Herein lies the greatest 
objection to this agent, for much of the chemicals sold in the shops is 
too old to be efficient. 

Formalin is a 40 per cent, solution of formaldehyd gas in water. 
In solution its action is not as effective as would be expected, and there- 
fore it has not come into general use. As a gas, its potency is note- 
worthy and has been discussed under Aerial Disinfection. 

The Sick-room in Infectious Diseases. — Infection may be carried 
in the sputum, in the throat secretions, in discharges from the nose 
and ear, in skin debris, in exudations, in conjunctival or abscess dis- 
charges, and in the urine or stools. The sick-room should be stripped 
of superfluous fittings; it should be in a remote part of the house, and 
preferably on the top floor. A large room with plenty of ventilation 
and sunshine and with an open flre should if possible be selected. A 
gown and hood should be provided for the physician and hung in a 
separate outside closet where it can be later disinfected. All clothing 
worn by the attendants in the sick-room should be washable, and a com- 
plete change should be made before mingling with the members of the 
household. When changes in linen are made for the patient or atten- 
dant the articles are to be rolled up in a bundle and put to soak for 
twenty-four hours in a carbolic (1 to 20) solution before being sent to 
the laundry, where the}'- are to be washed separately. 

When it is known that anyone has been exposed to an infectious 
disease, they should be isolated as soon as possible and given a bi- 
chlorid of mercury (1-5,000) bath and a complete change of clothing. 
Such individuals should be kept under close observation until the 
incubation period for that particular disease has passed. 

Scrupulous cleanliness with regard to the excreta and discharges of 



340 DISEASES OF CHILDREN. 

the patient is imperative. Soft Japanese paper napkins are most con- 
venient for wiping nose and throat discharges. They must be burned 
at once after use. Carbolic vaselin rubbed over the skin of patients 
suffering from variola, varicella and scarlet fever prevents the pus, 
exudations, and epithelial debris from drying and being scattered. 
Urine and stools should be treated with equal volumes of carbolic acid 
solution (1 to 20), bichlorid of mercury (1 to 1,000) or chlorid of lime 
(1 to 50), and allowed to stand three or four hours before disposing of 
them. Large masses in stools should be broken up to insure thorough 
disinfection. In cases in which the throat is involved, frequent gar- 
gles of chlorin water, potassium permanganate (1 to 300), formalin 
1 per cent, or peroxid of hydrogen reduce the number of bacteria 
in the expired air besides having a beneficial effect on the patient. 
Dishes and utensils used by a patient are to be placed for an hour in a 
large receptable containing carbolic solution (1 to 20) and then boiled 
or scalded. 

The remains of one dying of an infectious disease should be em- 
balmed with a fluid which will stand the bacteriological test. Close 
all external openings of the body with absorbent cotton and give a 
thorough sponge bath (including the hair) using carbolic solution (1 
to 20) or bichlorid of mercury (1 to 1,000). 

The following plan is recommended for the disinfection of the 
room where a patient with an infectious disease has been treated: 
1. Close all openings in windows, walls, and floors by calking or pasting 
strips of paper or adhesive plaster over them; 2. stretch out on a line 
all linen, blankets, and carpets contained therein; 3. spray with water 
the floors, walls, and all articles in the room; 4, introduce the disin- 
fecting gas and allow the room to remain closed up for twelve hours. 

The New York Board of Health gives the following directions: 

All cracks and crevices in rooms to be disinfected must be sealed 
or calked, to prevent the escape of the gas, and one of the following 
disinfectants used for room disinfection, in the quantities named: 

Sulphur, 4 lbs. for every 1,000 cubic feet of air space, eight hours' 
exposure. Formalin, 6 oz. for every 1,000 cubic feet of air space, four 
hours' exposure. Paraform, 1,000 grains for every 1,000 cubic feet of 
air space, six hours' exposure. The following disinfecting solutions 
may be used for goods which are afterward to be washed. Carbolic 
acid, 2 to 5 per cent. Bichloride of mercury, 1-1,000. 



CHAPTER XXIV 
TUBERCULOSIS. 

Tuberculosis is an infective fever caused by the toxins of the 
tubercle bacillus, and characterized by the formation of heteroneo- 
plasms called tubercles. Any organ or part of the body may be at- 
tacked. The disease may be confined to certain organs or may be 
generalized, occurring at the same time in many parts of the body. 

Etiology. — The tubercle bacillus upon which tuberculosis in any 
or all of its manifestations depends, is a rod-shaped, facultative, color- 
less bacillus, slightly bent and having rounded ends. In size it is about 
one-fourth to one-half the diameter of a red blood-cell. It is especially 
distinguishable for its staining properties. It strongly resists decolori- 
zation after having been stained with acid dyes. 

There are several varieties of the bacillus. We are mainly 
concerned here with the human and bovine types. The controversy 
regarding these types is not yet settled, but the distinction still seems 
to be a strong one between these forms. 

The bovine type of bacillus differs somewhat in form, being more 
irregular, thicker or oval in shape with blunted ends. The types may 
also be differentiated by cultural methods. This method, however, 
is suitable only for a laboratory specialist. 

The bacillus is easily destroyed by sunlight or heat, either dry 
or moist, but is not affected by low temperatures. 

The disease occurs at all ages — fetal tuberculosis has been re- 
corded (Jacobi, Wollstein, and others). 

The invading microorganism gains entrance to the body through 
three main channels, given in the order of their relative importance; 
through the respiratory tract, through the intestinal tract, and through 
wounds and abrasions of the skin. Infants and children are infected 
mainly through the respiratory tract. 

Hereditary predisposition is still the subject of argument, but the 
position held by Adami appeals to us. He believes that two possi- 
bilities may result from parental tuberculosis; the offspring may be- 
come especially susceptible if the germinal cells become weakened 
by progressive disease, or if the disease is well resisted the child may 
acquire an increased resistance to the disease. - 

341 ^^ ' 



342 



DISEASES OF CHILDREN. 



Parental diseases, nutritional faults and developmental defects 
in the parents often le^ve the offspring with a lowered resistance to 
tuberculosis. 

A child with poor muscular development, with a flat and narrow 
chest and small abdomen is considered to have a disposition to tuber- 
culosis; we can add to this 
class children who are mouth- 
breathers and have defects of 
the nose and mouth. 

In childhood there is little 
resistance to the disease; the 
glands, meninges, bones, joints, 
and lungs are easily invaded and 
are believed by v. Behring often 
to remain latent and develop in 
later life into the pulmonary 
form. 

Again, in childhood the 
disease is not apt to develop at 
the site of infection as in adults, 
but extends to other tissues and 
forms tubercles there. The 
entity known as scrofula is still 
acceptable to Continental 
Europe; but in America the 
weight of opinion is that scrofula 
indicates tuberculosis, and we 
believe with Baldwin that it can 
be used to mean an important 
predisposition to pulmonary 
tuberculosis, which he says is 
associated with it in 25 per cent, 
of all cases. Measles, whooping 
cough, diphtheria, pneumonia, 
influenza and, in a lesser de- 
gree, scarlet fever, tonsillitis, and variola are often the precursors of 
tuberculosis, because of their effect on the mucous membranes and 
lymph-glands accompanied by the lowered resistance of the conva- 
lescent child. 

Rickets, too, is a disease favoring tuberculous infection when 
accompanied by defective nutrition and thoracic deformities. Finally^ 
gastrointestinal diseases from their destructive action on the mucous 




Fig. 91. — Conformation of the chest com- 
monly seen in tuberculous children. 



TUBERCULOSIS. 343 

membranes lead sometimes to open infection and probably often to the 
latent form. 

The children of poor parents in unsanitary surroundings, whether 
in city or even in the country, are prone to the infection, which they 
may receive from the following sources: Human sputum, through 
food objects or dust, urine or feces on soiled clothing or beds. Milk of 
tuberculous cattle has been held as a distinct source of danger, but 
the case has not been fully proven. Certainly, bovine tuberculosis in 
our experience is a minor factor in the causation of the human form 
of the disease. Milk as a food, however, may be indirectly contami- 
nated by dust or infected containers. Infants at the breast have been 
infected by their mother's soiled hands or her kisses. 

Cornet reports infection by midwives who blew into the mouths 
of the infants to start up respiration. 

Children are intimately connected w^ith the fact, that tuberculosis 
is a '^family disease" — 40 to 60 per cent, disclosing a history of other 
cases in the household; and this close contact is the great infecting 
method : the nursling infected by close touch with its mother, the creep- 
ing infant on the contaminated floor carrying all things to its mouth, 
the school boy trading toys — all show at a glance the numberless ways 
in w^hich children may become tuberculous. 

Tuberculous Adenitis. 

This may be confined to certain groups of lymph-glands, as the 
cervical or bronchial, or there may be an involvement of all, or nearly 
all, the lymph nodes of the body. 

The glands become infected by access of tubercle bacilli through 
the lymph channels. The point of entrance may have been only a 
slight abrasion or some form of dermatitis. The glands may also 
become infected from tuberculous lesions in their vicinity. 

A cross section of a tuberculous gland shows the parenchyma 
swollen and hyperplastic, grayish in color, containing nodules varying 
in size, some of which are undergoing caseation. If the latter process 
is advanced, the gland is soft and the tubercles are found at the margins 
only. The glands most commonly involved are those at the root 
of the lung. The mesenteric lymph nodes are frequently infected in 
children and are the usual accompaniment of the miliary and general- 
ized forms. 

Symptomatology. — The subjects of tuberculous adenitis are, as a 
rule, anemic children of the blond type. The appetite is capricious 
or lost, the weight decreases, and at this time the parent may notice 



344 



DISEASES OF CHILDREN, 



an enlargement of a gland or group of glands. They are not painful 
to the touch, growing slowly but steadily; sometimes there is a rise 
of fever, especially in the evening. Physical examination may show 
tuberculous lesions elsewhere in the body. If the cervical lymph 
nodes are involved the tumors are at first found in relation with the 
sternocieido mastoid muscle. At first they are freely movable,, but 
the chain of glands increasing, they soon adhere one to the other, 




Fig. 92. — Tuberculous adenitis of the cervical and axillary glands. 



forming sometimes large masses which may even cause mechanical 
obstruction. Bilateral involvement is not uncommon. The overlying 
skin now becomes attached to the mass below, and when the glands 
caseate the skin is thickened and loses its normal color, often becoming 
purplish-red. If there is no surgical intervention the glands rupture 
through the overlying skin or dissect the fascial planes; the abscess 
may discharge at some distant point. Often several long-persisting 
fistulous tracts result. 

In the generalized form, the cervical, inguinal, and axillary 



TUBERCULOSIS. 345 

glands show the greatest and earliest involvement. The children are 
markedly anemic and often have a variable amount of temperature. 
Wasting slowly takes place and new foci are found developing in 
other parts of the body. Bimanual rectal examination will show 
fhe involvement of the retroperitoneal and mesenteric lymph nodes. 

When the bronchial lymph nodes are large, pressure symptoms 
may occur, causing a paroxysmal cough with breathing signs of 
bronchial asthma. In advanced cases dyspnea is produced on slight 
exertion. Sometimes dullness is obtained on percussion over the 
manubrium which extends over a varying area. This is usually 
accompanied by tubular breathing on the left side. 

Diagnosis. — The diagnosis of tuberculous adenitis is based upon 
the slow course and the absence of active inflammatory changes, such 
as heat or pain on palpation. Simple adenitis can usually be traced 
to some source of infection, as an eczematous area, caries of the 
teeth, etc. These glands subside when the focus of irritation is re- 
moved. If there are evidences of tuberculosis in other structures, 
tuberculous adenitis may be suspected. 

The tuberculin tests (p. 64) may be used to corroborate the 
diagnosis. Syphilitic glands are distinguished by their location. 
The epitrochlear glands show simultaneous enlargement with other 
syphilitic manifestations in different parts of the body. 

Lymphosarcoma is sometimes confounded with generalized 
tuberculous adenitis. This disease usually primarily involves the 
retroperitoneal glands or those within the mediastinum. The growth 
here is rapid, invading neighboring structures, and often producing 
serious symptoms before the true nature of the disease is suspected. 

Course and Prognosis. — It is often difficult to predict the end- 
result of a tuberculous adenitis. The prognosis should always be 
considered seriously as a focus which may at any time spread the 
disease to the lungs or other structures. 

If the subject is young and can be placed in favorable sur- 
roundings, restitution to the normal may take place. Even degener- 
ated glands with fistulous tracts may eventually terminate in a cure 
under proper care. 

Treatment. — Immediate steps should be taken just as soon as the 
diagnosis is certain to remove the child, if possible, to the seashore, 
where it should live in the sunshine and fresh air. The diet should 
be as nourishing as possible, consisting principally of milk, eggs, 
cereals, and rare meats. Cod-liver oil, if well borne, should be given twice 
a day, after the midday and evening meal. If this is not acceptable, 
good results can be obtained by increasing the quantity of butter, 



346 . DISEASES OF CHILDREN. 

cream, or top milks. Sometimes olive oil in two-dram doses twice 
a day can be substituted if the child prefers it. 

Surgical removal of the glands may be considered when they are 
superficial and movable. The dissection is often long, tedious, and 
dangerous when the glands are deep and are in proximity to the great 
vessels. General miliary tuberculosis may follow the removal of 
glands when a clean dissection is impossible. However, it is some- 
times necessary to resort to removal for the cosmetic effect or for the 
relief of pressure symptoms. Good results have been obtained in a 
number of cases from radiotheraphy and it would seem best to counsel 
non-interference until these measures have been given a fair trial. 

Thoracic Tuberculosis. 

It is only within recent years that the frequency of pulmonary 
tuberculosis in early life has been correctly appreciated. From a 
study of all necropsies in children under fifteen years of age, Harbitz 
at Christiana found tuberculosis in 42.5 per cent, of all. Denning 
shows that 70 per cent, of all infants and children who die from 
tuberculosis show tuberculous changes in their lungs. Pediatrists 
incline toward the respiratory tracts, while pathologists lean toward 
the alimentary tract as the principal portal of entry; the contro- 
versy, with much to be said on both sides, concerns us in regard to 
prophylactic measures to be spoken of below. 

Tuberculosis in early life increases regularly with the age. It is 
rare in the first three months of life, and then almost, month by month, 
the frequency increases steadily. The figures of Hamburger and 
Sluka, obtained from 2,557 necropsies on tuberculous children under 
fifteen years, report that tuberculosis was the direct cause of death 
in all,those under six months of age; that it caused death in 75 per cent, 
of those in the second year of life, and in the children over two years 
old it became more infrequently the cause of death. Necropsy find- 
ings, however, are not absolute indications of the prevalence of tuber- 
culosis in early life since virulent bacteria may be present without 
producing demonstrable lesions. 

Tuberculosis in early life is a disease of the lymph nodes, but 
after the tenth year the pulmonary form is more prevalent; and again 
after adolescence the characteristics do not differ greatly from those 
seen in adults. 

Pulmonary involvement may occur by direct infection from ca- 
seous tuberculous glands through the blood stream or by emboli, and 
through the lymph channels from tuberculous lymph nodes, bones, or 
pleura. 



TUBERCULOSIS. 347 

Pulmonary Lesions. — The pathological anatomy does not differ 
greatly from that seen in adult life, but the areas involved are always 
greater; in other words, the disease is more diffuse. This is especially 
true in the first two years of life. 

In tuberculous bronchopneumonia, which is the predomi- 
nating and fatal form, there occur large caseating deposits usually to some 
extent in both lungs. When a mixed infection occurs the nodules are 
very apt to degenerate. True cavities of any size, however, are rarely 
seen in early life. The glands at the root of the lung are invariably 
enlarged and often soft and caseating. The pleura is almost always 
involved. 

In miliary tuberculosis of the lungs, the tubercles are scattered 
over the surface of the lung, and in some cases have been found 
in the parenchyma. Patches of bronchopneumonia and congestion 
with edema may be present, or the lung may appear quite normal ex- 
cept for the superficial tubercles. 

Diagnosis. — The diagnosis of incipient tuberculosis of the lungs 
differs considerably in early life from that of adults. In the first 
place the apices of the lungs are not most frequently involved; it is 
the lower lobes or the lower part of the upper lobe that is primarily 
involved, which may often be accounted for by the proximity of the 
bronchial glands. The physical signs often do not differ from those 
obtained in bronchitis and bronchopneumonia, and the younger the 
child the more diffuse will be the disease. Therefore it is necessary 
to employ every means at our command to perfect the diagnosis. 
The physical signs with the symptoms and the history then become of 
value. 

In obtaining a history in suspected children, it is especially im' 
portant to ascertain if the child has been in intimate or close contact 
with a tuberculous patient, or if there has been a slow convalescence 
from any of the infectious diseases, especially measles and pertussis. 

Gibson has called attention to a venous dilatation occurring over 
the chest, neck, and shoulders of children, and tending to converge 
above the sternum. This, w^hen present, is a valuable sign, and it is 
probably due to tuberculous bronchial lymph nodes. If we could 
safely and surely diagnosticate enlarged bronchial lymph nodes we 
would have valuable confirmatory evidence. D'Espine says he has a 
reliable method in voice auscultation; in the healthy child the tracheal 
tone stops at the seventh cervical spine, but is heard below this point 
in pathological conditions. Later on, dullness over the seventh cervi- 
cal or first dorsal vertebra with intrascapular dullness may be elicited. 
Cavity formation is rarely recognized under three years of age, while 



348 DISEASES OF CHILDREN. 

after eight the signs will simulate those in the adult. Expectoration 
is the exception in children, while under seven years hemoptysis rarely 
occurs and practically is never observed in those below five years old. 

Three groups of thoracic tuberculosis may be distinguished in 
children; the glandular, tracheobronchial, and the pulmonary. The 
symptoms are never so characteristic as in the adult; as a rule, there 
is a rapid development of symptoms. If we encounter steady emacia- 
tion, progressive muscular weakness, an irregular temperature with a 
fairly constant evening rise, enlarged superficial glands, with a per- 
sistent dry cough, we are justified in utilizing diagnostic aids to confirm 
the diagnosis. 

In adults, a diagnosis may sometimes be made by physical signs 
before the tubercle bacilli are found in the sputum. In infants and 
young children, however, we are pleased if we obtain any sputum to 
examine, and must be prepared to make diligent search for the bacillus. 
Among the methods used with success in obtaining sputum from in- 
fants is wrapping a piece of gauze on the end of the finger and irritating 
the epiglottis thus catching the sputum. We use an ordinary laryn- 
geal swab wrapped with cotton which is quite effective and does no 
damage to the delicate mucous membranes. The sputum being often 
swallowed, the vomitus or the feces will also contain the bacilli, but the 
search is more arduous. 

The opsonic index has been studied by numerous investigators 
in its relation to tuberculosis, and is considered of value in obscure 
cases. Clark and Forsyth have made careful studies, and base their 
diagnosis on the following variations: (a) the greater the fluctuation, 
the greater the certainty of diagnosis; (b) a persistently low index is 
diagnostic of localized tuberculous infection; (c) a persistently normal 
index does not exclude tuberculosis, but makes it less probable; (d) a 
persistently variable index is diagnostic of tuberculous infection with 
autoinoculation. 

Ross states that he has never found an index of 1.3 in a patient 
not definitely tuberculous. Ogilvy and Coffin, as a result of their 
studies, believe that the difficulty and tedious technic of estimating 
the opsonic index and the wide variation obtained by various observers 
make this procedure impracticable for diagnosis. 

Injections of tuberculin may be used diagnostically as a last 
resort if it is imperative that a definite diagnosis be made. In children 
the reaction is more favorable than in adults. Its use, however, is 
limited to those cases without temperature. The dose which is safe 
in children is one ten-thousandth of a c.e. of Koch's old tubercuHn, 
one three-thousandths beino; the maximum dose. . _■ 



TUBERCULOSIS. 349 

The agglutination and the heated serum tests have been tried, 
and the reports are quite uniformly against their practical value. 
Other tests, however, have attracted considerable attention and they 
are especially applicable in children. 

Von Pirquet advanced the inoculation of Koch's old tuberculin 
into the skin in two areas, leaving one area for control. Von Pirquet 
uses one part tuberculin, diluted with one part of a 5 per cent, carbol- 
glycerin solution, and two parts normal saline solution, of this two 
drops are inoculated. The writer has used one part tuberculin to three 
parts saline solution freshly prepared. Butler sums up his extensive 
observations as follows: (a) a positive reaction is undoubtedly 
diagnostic; (b) failure may be expected in the terminal stages; (c) 
negative results may be obtained in obsolete foci unless repeated. 
He believes the method has distinct advantages over the hypoder- 
matic use of tuberculin. Calmette, simultaneously with Wolf-Eisner, 
proposed the ocular method in which a 1 per cent, solution of dry 
tuberculin in distilled water is dropped upon the lower eye-lid of the 
eye. In three to five hours a reaction occurs, varying from a slight 
conjunctivitis to a purulent secretion. This test has been quite 
favorably received, and indeed is of distinct value in establishing an 
earl}^ diagnosis. Wolf-Eisner interprets a lively reaction as indicative 
of incipient tuberculosis, coupled with a favorable prognosis, for the 
organism is then active against the tubercle bacilli. He believes the 
eye test to be of greater value clinically than the cutaneous, but would 
use the cutaneous as a control. The presence of conjunctivitis, bleph- 
aritis, ulcers, or trachoma are contraindications for the use of the 
ocular test. 

The Moro test, described on page 65, is simpler to perform, 
causing no distress or unpleasantness except slight itching. It may be 
used alone or as a confirmatory test to the other methods. 

Pulmonary Tuberculosis. 

Acute and Subacute Forms. — Etiology. — Mainly through the bron- 
chial lymph nodes, the infection is carried to the lungs of infants and 
children; the lung may be more directly affected, however, through the 
impoverished mucous membrane following certain infectious diseases. 
Tuberculosis in other structures predisposes to lung infection. The 
generalized process in the lungs is part, and usually the termination, 
of a miliary tuberculosis, while the localized process is most often 
found close to the bronchial glands. 

Acute tuberculous bronchopn-eumonia in infants and young 



350 DISEASES OF CHILDREN. 

children does not markedly differ in its physical signs from the simple 
bronchopaeumonia, but the period of illness sometimes lasting from 
two to six weeks must be suggestive. 

The fever is generally lower and with smaller excursions than in 
the ordinary form until the toxemia itself produces high evening 
rises up to 103° or 104° F. Loss of weight is slow but progressive. 
The appetite is capricious, the patient is irritable, easily tired and at 
times somnolent, the bowels are, as a rule, constipated, although 
diarrhea may periodically appear. 

The fever causes restlessness at night and in the morning. The 
body and clothing may show that sweating has taken place. The 
cough is paroxysmal in character, and is apt to be more frequent 
upon awakening. As the disease progresses, circulatory changes are 
evidenced by cyanosis in the finger-tips and lips. . Dyspnea is easily 
caused by slight exertion or coughing. Hemoptysis is exceedingly 
rare in children. If death does not supervene, the affection may 
appear elsewhere, as in the brain, intestinal tract, or in the glandular 
structures. 

Physical Signs. — These may not differ from the ordinary broncho- 
pneumonic type of the disease. Occasionally only are there signs 
of cavity formation, or well-developed signs of bronchial and peri- 
tracheal glandular hypertrophy.. The latter signs, if obtainable, are 
of distinct diagnostic importance. 

The examination of the sputum, obtained with a laryngeal swab 
or from the stomach contents, urine, and feces, may reveal the pres- 
ence of tubercle bacilli. / 

Chronic Pulmonary Tuberculosis. 

This form is rarely seen under five years of age. In the cases 
that have come under our observation, the tuberculous process was 
extremely diffuse in character. The physical signs do not markedly 
differ from those of the adult type. 

Progressive loss of weight, night-sweats, extreme anemia with 
high leukocytosis, and frequent attacks of gastroenteritis are the 
symptoms which finally precede death. 

At any age the pleura may become involved in the tuberculous 
process, and an empyema result. > The pus in these cases is thinner 
and more watery in consistency, and only rarely can the tubercle 
bacilli be isolated. \ These cases do not tend to recovery; further lung 
involvement takes place, and death often results with meningeal 
symptoms. \ 



TUBERCULOSIS. 



351 



Course. — The course of the disease in early Kfe varies with the 
form. (There is a latent form in which the characteristic features are 
irregular fever^ rapid emaciation, and late pulmonary signs. The 
affection runs a speedy course, terminating sometimes in a few 
days to a fortnight. ' The child with the bronchopneumonic or the 
more usual var^"ety may live several weeks. In exceptional cases the 
patient has lived six months. The chronic form, under favorable 
circumstances, such as the modern sanatorium treatment gives a more 
favorable prognosis; that is, there is a tendency toward arrest of 
the process. ] 




Fig, 93. — Clubbed fingers in chronic pulmonary tuberculosis. 



Acute Miliary Tuberculosis. 

This is an acute general infection with tubercle bacilli, occurring 
at any period of childhood. As a rule, it is secondary to some primary 
focus in the body, which may have been dormant for some time. 

Etiology. — Measles, whooping-cough, and tuberculous lymph 
nodes are the exciting causes. The disease occurs quite commonly in 
early life, especially the meningeal form or tuberculous meningitis. 
McCrae had forty-three cases of generalized miliary tuberculosis in 417 
autopsies on tuberculous individuals, among these were fifty-five 
children. The meninges were involved in twenty-one, and the tho- 
racic lymph nodes in thirty-three cases. 

Two forms of the disease are recognized — the general and local — 
based upon the symptoms. 

In the general form the symptoms in the early stages, are such as 
to simulate beginning typhoid. There is irregular fever with no 
characteristic curve malaise, loss of appetite, slow emaciation at first, 



352 DISEASES OF CHILDREN. 

becoming more marked as the disease progresses. The pulse is in- 
creased out of proportion to the temperature. Rapid, shallow 
breathing is later followed by the Cheyne-Stokes type as the disease 
progresses, or if meningeal symptoms intervene. Vomiting is often 
an early symptom. 

The spleen is enlarged almost invariably and the liver, too, is 
often increased in size. A disturbing slight cough is generally present. 
The urin contains traces of albumin and hyalin casts, and occasion- 
ally tubercle bacilli can be found. Inoculation tests from the blood 
may confirm the diagnosis. The younger the child the more often 
does the meningeal form bring on a rapid termination. Delirium, 
stupor, and coma denote cerebral involvement. The usual course is 
from three to six weeks. The prognosis invariably is hopeless. 

Differential Diagnosis. — The Widal test and the more typical tem- 
perature curve, with the characteristic eruption, plus the relative 
increase in the mononuclear elements in typhoid, must be depended 
upon to distinguish this form of tuberculosis from typhoid, although 
this is sometimes extremely difficult. In miliary tuberculosis, besides 
the tuberculin test, an ocular examination may, especially in the later 
stages, show tubercles in the choroid, or fluid withdrawn from the 
spinal canal may show tubercle bacilli. 

Local Manifestations. — Miliary involvement of the lungs usually 
occurs after measles or whooping-cough, or is secondary to a broncho- 
pneumonic process. The physical signs offer no help in differentiation. 
The diagnosis in children is extremely difficult until the disease has 
progressed to some other structure, as the brain, when more character- 
istic symptoms are obtainable. 

Tuberculous Meningitis. 

The tubercle bacilli spread from some focus of infection through 
the lymph channels or blood current to the meninges, and usually form 
an eruption of miliary tubercles at the base of the brain, spreading up 
to the vessels in the fissure of Sylvius. An inflammatory exudate 
is almost invariably found in the space between the optic chasm and 
the peduncles. The exudate is yellowish-green in color, tenacious 
and adherent to the pia mater. The ventricles are more or less 
distended with fluid, in some instances forming a distinct internal 
hydrocephalus. The ependyma if carefully removed is found to be 
rough, edematous, and may be infiltrated with tubercles. The pia 
mater is injected with a serofibrinous or seropurulent infiltrate. 
Not infrequently the tubercles are seen in the choroid plexus. Occa- 



TUBERCULOSIS. . 353 

sionally there is only a slight amount of exudate, and the infection is 
found to be localized in the form of one or more nodules, some the size 
of hickory-nuts which are known as solitary tubercles of the brain. 

Etiology. — Tuberculous lymph nodes which have become diseased 
as a result of the acute infectious diseases, especially pertussis and 
measles, play the principal role in the causation. A latent tuberculous 
focus may set free the tubercle bacilli into the blood stream. A tuber- 
culous osteitis or an infection in the uropoietic system may be resjDon- 
sible for the meningeal involvement. A number of cases seem to be 
traceable to a chronic otitis media. Unsanitary surroundings, espe- 
cially in a tuberculous environment, predispose to the disease. On the 
other hand, it occurs among the well-to-do, and may attack a child that 
has been considered exceptionally healthy. It commonly occurs 
below the age of five years./ Infants of five months have been reported 
who have died of the disease. (Rilliet). In Koplik's series of fifty- 
two cases, eleven were less than one year old, while the average age 
was slightly over four years. 

Symptomatology. — It is impossible to give a typical description 
of the symptoms of this disease, so varied are its manifestations. 

The prodromal symptoms usually come on gradually and insidi- 
ously. / A previously healthy child becomes irritable, morose, and 
refuses to play. / Lassitude, coated tongue, loss of appetite and occa- 
sional vomiting are, as a rule, attributed to digestive disturbances. / 
If the child is old enough, headache, dull in character, is complained of. / 
Progressively the symptoms grow more marked until signs of cerebral 
irritation appear. ' Occasionally the onset is abrupt with fever, vomit- 
ing, and pressure symptoms. 

The diagnosis may not be suspected until the child refuses to 
leave the bed. The pulse rate in infants is usually increased; in 
older children it may be irregular in character. ' Vomiting occurs 
irregularly and with no regard to the food ingested.,' The temperature 
is not high, rarely over 101° F. and may be normal during the morning 
hours. /The mentality is dulled and the child is aroused with diffi- 
culty. ' The food is taken without protest or interest. Infants 
may show increased tension by a bulging fontanel. A high-pitched 
scream, which if once heard is easily recognized and known as the hy- 
drocephalic cry, often accompanies the headache which may now 
be intense. Except in infants the abdomen becomes flat or sunken 
in the later stages, forming the so-called scaphoid abdomen. Con- 
stipation is the rule. / Rigidity of the muscles of the neck may be noted, 
but distinct retraction may never occur or only in the final stages. 
There may now supervene irregular or associated ataxic movements 

23 



354 



DISEASES OF CHILDREN, 



The respirations are slow and irregular, with the inspiration prolonged 
and sighing. The pupils may be unevenly contracted and react 
slowly or not at all to light. Nystagmus may be an early symptom, 
while conjunctivitis, strabismus, and pto&is usually appear in the final 
stage. Marked apathy with delirium and coma supervene. Occa- 
sionally convulsions may occur. The pupils are now almost constantly 
dilated. The extremities are rigid or spastic, although paralyses, mono- 
plegic or hemiplegic in type, may appear before the terminal stage. 




Fig. 94.- 



-a, Tuberculous meningitis; patient semi-comatose; b, tuberculous 
meningitis; last stages, coma absolute. 



The respirations tend now to the Cheyne-Stokes type. The final 
stage is usually known by the frequent convulsive seizures. The 
emaciation is now rapid, the pulse becomes small and irregular until 
the agonal stage. The eyes are sunken. Edema of the lungs may be 
found on physical examination. The rigidity of the neck is supplanted 
by paralyses in various parts of the body. Examination of the fundus 
usually shows an optic neuritis. The urine and feces may be involun- 
tarily passed. The temperature toward the end may rise to 105° 
or 106° F., or there may be a sudden drop to subnormal. 

The reflexes are usually inhibited in this stage. Kernig's sign 
and the Babinski reflex are present in about 50 per cent, of the cases. 
MacEwen's sign, or a tympanitic note on percussion over the ventricles, 
is obtained in those cases in which there is an internal hydrocephalus. 
If obtained in children over two years of age, it is of value in establish- 
ing the diagnosis. 



TUBERCULOSIS. 355 

Lumbar puncture is of great importance in making the diagnosis 
and sometimes is the only practical method of making the specific 
diagnosis. In this form of meningitis the fluid frequently flows out 
under increased pressure; it usually is clear and contains a greater 
amount of protein than normal. 

Fehling's solution occasionally is reduced by the fluid. If the 
proper technic is followed, the presence gf tubercle bacilli can be 
demonstrated, although such expert labor should be placed in the 
hands of a trained pathologist. Inoculation experiments into animals 
may also be made for confirmation. Mononuclear cells, sometimes 
over 90 per cent., are present in the fluid. 

Course. — The duration is usually from three to four weeks. 
Occasionally there are periods of apparent improvement, which may 
give rise to a false hope of recovery. On the other hand, cases have 
remained under our observation for many weeks with slow and pro- 
gressive emaciation, finally terminating fatally. 

Diagnosis. — The slow onset, the lack of hyperesthesia, the slower 
pulse and respiration, and the type of temperature curve, with the 
aid of lumbar puncture, are the only definite means of differentiation 
from the cerebrospinal type. 

Some intracranial diseases may in their incipiency lead to con- 
fusion unless the characteristic symptoms of a meningitis are sought 
for. 

Prognosis. — Although there have been several reported cures in 
cases in which tubercle bacilli were found after repeated lumbar 
punctures, the disease must be regarded as quite hopeless. 

Treatment. — Quiet and rest, with bromids for the relief of the 
nervous symptoms, and lumbar puncture for the relief of intra- 
cranial pressure, with frequent repetition of this procedure if followed 
by amelioration of the symptoms, are indicated. The diet, usually 
liquid, is taken in a bottle or may be given by gavage. lodid of 
potash and inunctions of mercury have proved valueless in our hands. 

Tuberculous Peritonitis. 

Tuberculous peritonitis is a comparatively rare affection, although 
this variety of peritonitis is more frequently seen in childhood than 
the non-tuberculous forms, and a diagnosis, first as to the condition 
itself, and then as to its particular variety, is of importance because 
of the direct bearing on the prognosis and surgical treatment. The 
peritoneum may become involved from a tuberculous focus in any 
part of the body. The disease is nearly always secondary and the 



356 



DISEASES OF CHILDREN. 



infection is carried through the lymphatics or blood stream. Bovaird 
in 125 cases of general tuberculosis found the peritoneum involved in 
7 per cent. 

From an anatomical standpoint four forms are usually recognized. 
Miliary, miliary with ascites, the ulcerative, and the fibrous variety. 

The miliary form is met with in 
cases of general infection. It is practi- 
cally impossible to make antemortem 
diagnosis of this form. The tubercles 
are found scattered over the peritoneum 
and intestines in large or small numbers. 
Adhesions form, binding the viscera to 
themselves, to the neighboring organs, 
and the abdominal wall. On opening 
the abdominal cavity a serous or 
seropurulent fluid is found. The peri- 
toneum is clouded and streaked with 
lymph. In older cases adhesions form. 

The Ulcerative or Caseating 
Form. — ^Postmortem findings in this 
variety show caseating foci in the peri- 
toneum. Lymph or pus takes the place 
of ascitic fluid. The intestinal coils are 
matted with fibrinoplastic deposits. The 
abdominal wall may also be found ad- 
herent to the intestines. Tuberculous 
masses are found scattered over the 
parietal and visceral peritoneum, while 
in some cases ulcerations occur. The 
glands are usually greatly enlarged, and 
may be found in sacculations filled with 
purulent fluid. Fistulous tracts may 
occur and perforate at or near the 
umbilicus. 

The fibrous form rarely gives evi- 
dences of an effusion. There is an abundance of lymph on a thick- 
ened peritoneum, studded with miliary tubercles. The peritoneal 
cavity may be completely obliterated by the dense matting and firm 
adhesions. Rolls of omentum are occasionally seen, covered with 
fibrous tissue. The intestines themselves adhere to each other. 
The characteristic of this form is a tendency to the formation of 
cicatricial tissue. 




Fig. 95. — The ascitic form of 
tuberculous peritonitis. 



TUBERCULOSIS. 357 

Symptomatology of the Special Forms. — Ascitic Form. — The 
symptoms may be very insidious. There is a slow but steady 
increase in the size of the abdomen, and constipation alternates 
with diarrhea. There may be vomiting, the appetite is capricious 
or lost. Careful examination may now elicit fluid in the abdominal 
cavity. 

The superficial veins over the abdomen and lower chest are 
prominent. There is an evening rise of temperature, and progressive 
emaciation is noted. Rectal examination may disclose peritoneal 
nodules and enlarged mesenteric glands. An acute form is occasionally 
seen in which the symptoms simulate an inflammation of the small and 
large intestines. The fever is quite high, the abdomen rapidly becomes 
distended with fluid. The prognosis is better in the insidious form. 

Ulcerative Form. — The symptoms are those of various grades 
of enteritis. There is vomiting, constipation or diarrhea, abdominal 
pain, loss of appetite, with occasionally bloody stools. The fever is 
quite high, irregular in type with occasional sweating, especially on 
exertion, and considerable prostration. 

Percussion shows areas of dullness or flatness, alternating with 
areas of tympany. Bimanual rectal examination may give strong 
evidence of the matted condition of the intestines. Occasionally 
the stools contain blood. Pus may be discharged through openings 
near the umbilicus. Emaciation is extreme, and the end comes 
through asthenia. 

Fibrous Variety. — The sj^mptoms come on very gradually 
with some colick}- pains in the abdomen. The bowels are usually 
constipated. There is some distention of the abdomen. Nausea and 
vomiting or symptoms of obstruction may lead to a careful examina- 
tion of the abdomen, and the masses or rolls of omentum with some 
intraabdominal fluid may assist in establishing the diagnosis. 

Diagnosis. — A child between the ages of one and six years who has 
lived in an environment of tuberculosis or whose vitality has been 
lowered by an infectious disease, and who is languid, peevish, and has 
an evening rise of temperature with some enlargement of the abdomen, 
should be carefully examined for tuberculous peritonitis. The child 
ma}^ present the phthisical habitus or only appear to have lost some 
flesh. The skin is almost constantly dry and harsh. Passing the 
hand lightly over the abdomen, subcuticular nodules about the umbili- 
cus are often felt. Fluctuation may be readily made out, or a sus- 
picion of fluid onl}' may be found on palpation and percussion. Bi- 
manual rectal examination in the semirecumbent position should now 
be made to confirm the presence of fluid and to further ascertain the 



358 DISEASES OF CHILDREN. 

condition of the intestines, whether they are free or bound by a fibrino- 
plastic exudate. One accustomed to the normal conditions as found 
by the examining finger in children will appreciate the changes pro- 
duced by a plastic exudate, and may furthermore feel hypertrophied 
mesenteric lymph nodes and a band of adhesions running transversely 
across the abdomen. If the process has so far advanced that rolls of 
omentum, or agglutinated masses of mesentery and intestine have 
formed, palpation over the abdomen and the finger in the rectum 
will readily reveal the presence of these tumors. The abdomen may 
then appear flat or gas-distended, and Thomayer's sign of dullness on 
percussion on the left side of the abdomen, with a tympanitic note on 
the right side, may be obtained; in this latter condition fluid is rarely 
made out before operation, and only small quantities are seen on 
opening the abdomen. 

In the early stages of the ascitic form we should if possible exclude 
circulatory, renal and hepatic disturbances, and abdominal growths. 
The general nutrition may still be fairly good. The fluid readily gravi- 
tates to the dependent section on change of position. Corrobora- 
tive evidence may be obtained by finding Marfan's symptom, that 
is, the presence of pleuritic friction rales at the base of the lungs, 
sometimes associated with small exudations into the pleura. Pain 
is rarely obtained on palpation, but indefinite colicky pains are com- 
plained of. If, coupled with the above symptoms, the skin is harsh 
and dry, and subcuticular nodules are present over the abdomen, the 
diagnosis, now fairly certain, should be confirmed by laboratory and 
tuberculin tests. The frequent use of the thermometer showing pre- 
dominating small evening rises and the presence of large numbers of 
lymphocytes always tend in favor of a tuberculous process. In a 
tuberculous peritonitis the mononuclear leukocytes are generally 
increased. Cytological study of the tapped ascitic fluid may also assist 
in confirming the diagnosis. The diagnosis in the first form is not 
always certain without further tests, and even the last-described variety 
may cause confusion. 

If a chronic peritonitis of the tuberculous variety is suspected, 
a very thorough examination of the entire body should be made for 
possible tuberculous disease in other organs not only to confirm the 
diagnosis, but to determine what shall be the character of the treat- 
ment and the prognosis. For if the lungs are involved and the spleen 
and liver are enlarged, general miliary tuberculosis is in all probability 
present, and the patient is beyond the hope of recovery. Whether or 
not the peritoneal process is tuberculous may be confirmed either by 
the skin-inoculation test of Von Pirquet, by the Moro reaction (i.e., a 



TUBERCULOSIS. 



359 



50 per cent, tuberculin ointment) or by the Calmette test; but this is 
not recommended if there is any possibility of corneal involvement. 
The catheterized urine may be centrifuged for the presence of tubercle 
bacilli, or inoculation tests can be made with guinea-pigs. 

Treatment. — The trend of opinion, buoyed up by some successful re- 
sults in recent years, tends toward operation in all cases of tuberculous 
peritonitis, especially as the operation is comparatively simple and not 
dangerous to life. If more regard had been paid to the general ex- 
amination and only selected cases operated upon, the statistics would 
have been steadily in favor of operation. The ascitic form of local- 
ized tuberculous peritonitis does well under laparotomy, the plastic 
form rarely does well; fistulae are apt to form, and the lungs frequently 
show early involvement following the laparotomy. Again, if the di- 
agnosis can be made early in the ascitic form non-operative interference 
may be counseled provided the circumstances are such that all the 
anvantages accruing from life at the seashore, rest and nutritious food 
are possible. Otherwise the child should be watched, and if the exudate 
is on the increase operation should be recommended. A life in the 
fresh air, confinement to bed while an active process is going on, 
food high in proteids and fats, with the addition of cod-liver oil and 
the syrup of the iodid of iron are indicated after laparotomy, and for 
the inoperable cases. 



Bone and Joint Tuberculosis. 

{Caries of Bone.) 

This affection is the result of the invasion 
of tubercle bacilli in the spongy portion of 
the bone. Usually beginning as a single focus 
it spreads and often involves the whole epi- 
physis. Tubercles are formed which later 
may degenerate, forming many necrotic areas 
which may merge to form a caseating area. 
Granulation tissue is found at the periphery. 
M_ ;( ^ ^ In some instances a sequestrum forms or an 

K J W- abscess results. The joints are infected 

Wm W^ ^ through the cartilage, and the disease rapidly 

!^ spreads to the synovial membrane where 

ulcerations form. When the cartilage be- 
comes detached, destruction begins in the 
bare bone. In this way deformities so common in and about the 
joints are produced. 




Fig, 96. — Tuberculous 
dactylitis. 



360 



DISEASES OF CHILDREN. 



Etiology. — The infectious diseases, especially measles and scarlet 
fever, are probably more often the direct cause of tuberculous joint 
diseases than traumatism. Any devitalizing disease, however, must 
be considered as a factor. The affection is extremely rare in infants. 
After the third year it is distinctly a disease of childhood. 

Tuberculosis of the Vertebrae. 



(PoWs Disease; Caries of the Spine; Spondylitis.) 

This affection is the result of a tuberculous osteitis in the spongy 
portion of the bodies of the vertebra. 

It is extremely common in early childhood, and, according to 
Taylor, more than half the cases occur under six years of age. The 
dorsal region is most often affected; 
the cervical less commonly. 

Diagnosis. — If careful physical 
examinations were oftener made with 
the child completely undressed, the 
diagnosis would more frequently be 
reached in the early stages. The 
abnormalities which should attract 
attention are the rigidity of the 
spine, and in walking a deficient 
mobility of the spinal column when 
tested by the examiner. Deformities 
due to necrosis of the bone will be 
apparent on observation, often form- 
ing the familiar humpback. The 
peculiar attitude and gait assumed 
may attract attention, even before 
the child is undressed. 

In cervical Pott's disease, 
wry-neck may be the first symptom 
complained of. The differential 
diagnosis from other forms of torticollis is sometimes very difficult. 
The slower onset, the posture, and the general muscular fixation serve 
to distinguish it. 

Dorsal Pott's disease is distinguished by the erect military 
gait, the lateral deviation, with a bony deformity, which can be 
palpated and usually easily seen. 

Lumbar Pott's Disease. — Here the attitude of lordosis should 




Fig, 97. — Torticollis, due to cervical 
Pott's disease. (Bradford and Lovett.) 



TUBERCULOSIS. 



361 



attract attention, especially if accompanied with deviation to one side, 
and a careful abnormal gait. Hyperextention of the leg in the prone 
position elicits the sign of psoas contraction. 

Paralysis. — This may occur 
at any time in tuberculous spinal 
disease, although as a rule it occurs 
as one of the later symj^toms. 

The patellar reflexes are in- 
creased, ankle clonus may be pres- 
ent, and the pain, if absent before, 
is now present or increased in 
severity. 

A RACHITIC SPINE is often 
mistaken for Pott's disease. The 
curve, however, is rounded and 
the spine is supple. If the child 
is raised with the hands of th$ 
examiner in the axilla the curva- 
ture tends to disappear. Other 
bony changes or the symptoms of 
rickets may be present. The de- 
formity in Pott's disease does not 
disappear when the child is raised 
or is in the prone position. 

Treatment. — This is mainly 
orthopedic and involves the use 
of apparatus to promote spinal 
rest (Fig. 100) and the correction 
and prevention of deformities. 
The medical treatment encompasses 
dietetics and hygienic manage- 
FiG. 98. — Dorsal Pott's disease. ment. 




Tuberculous Disease of the Hip. 

{Hip-joint Disease; Morbus Coxa; Coxalgia.) 

This affection is due to a tuberculous osteitis of the head of the 
femur, of the acetabulum, or both. The disease usually begins 
gradually, the parents first noticing a limp. Night cries occur, but 
pain is a very variable symptom. The attitude assumed is one with 
a little flexion of the knee of the affected side and a slight tilting of the 
pelvis. In later stages of the disease much can be learned by testing 



362 



DISEASES OF CHILDREN. 



the child for freedom of motion, picking up objects, mensuration, pain 
and swelHng. The classical symptoms upon which a diagnosis can be 
based with certainty are limit of motion, muscular spasm, pain, 
swelling, attitude, shortening and atrophy of muscle. The X-rays 
and the tuberculin tests may be required in difficult cases. 




Fig. 99. — Lumbar Pott's disease. 



Treatment. — Immobilization and protection of the joint by casts, 
traction, and later, braces; a Hfe in the open air and good food do 
much to assist the orthopedic measures. Osteotomy and excisions 
are performed only in desperate cases. 



TUBERCULOSIS. 



363 



Tuberculous Disease of the Knee. 

{Gonitis Tuberculosa; White Swelling.) 

The epiphyses are nearly always primarily involved. It is most 
commonly observed in children, and, after the spine and hip involve- 
ment, it occurs most frequently. 

The diagnosis is usually quite 
readily made, as the knee-joint 
easily lends itself to examination. 
Swelling, with lameness which may 
be intermittent, are the first 
diagnostic symptoms. Stiffness 
and pain, follow. Muscular spasm 
on passive motion may be observed. 
The knee may be held in a posi- 
tion of flexion. Infectious synovitis 
is distinguished by the more rapid 
onset, temperature, and signs of 
localized inflammation. 

Chronic synovitis is very slow" 
in its course and is not accom- 
panied by much lameness or pain. 
Sometimes crepitus may be ob- 
tained. Eventually a true tumor 
albus may result. The X-rays, 
tuberculin, and inoculation tests 
may be made if necessary. 

Treatment. — The medical 
treatment does not differ from that 
of tuberculosis elsewhere. The 
joint should be encased in a splint 

Fig. lOO.-Infant with Pott's disease on which will prevent joint motion of 
a Bradford frame. the knee and foot. . 




Treatment of Tuberculosis in General. 

Prophylactic. — There are but few diseases in which prophylaxis 
can accomplish so much for the child as in tuberculosis. Upon the 
physician and health officer the duty devolves, and it begins even 
before conception. It is largely a problem of sociology and preven- 
tative medicine. 

Laws which have lately been passed in many States prohibiting 
the sale of tuberculous milk and meat, tenement-house inspection. 



364 DISEASES OF CHILDREN. 

health-board notification, and the educational exhibits will all tend 
to decrease the spread of this disease. Tuberculous mothers should 
not nurse their children because of danger in the close contact. 

Milk for infant feeding should be obtained from tuberculin tested 
cows, or should have the stamp of approval of a medical commission 
as being ^'certified." Where this is not possible the milk may be 
pasteurized. 

The children of tuberculous parents should be brought up, if 
possible, in the country and early trained to live an outdoor life. 
Such defects as adenoids or carious teeth should be removed. They 
should be especially guarded from measles and whooping-cough. 

School houses should be so arranged that proper ventilation can 
be obtained in rooms with ample air space and sunlight. Teachers, 
who as a class are particularly susceptible to the disease, should be 
frequently examined. 

Knoff has formulated the following valuable set of rules for 
school children: 

Do not spit except in a spittoon or a piece of cloth or a handker- 
chief used for that purpose alone. On your return home, have the 
cloth burned by your mother or the handherchief put in water until 
ready for the wash. 

Never spit on a slate, floor, sidewalk, or playground. 

Do not put your fingers into your mouth. 

Do not pick your nose or wipe it on your hand or sleeve. 

Do not wet your fingers in your mouth when turning the leaves 
of books. 

Do not put pencils into your mouth or wet them with your lips. 

Do not hold money in your mouth. 

Do not put pins in your mouth. 

Do not put anything into your mouth except food and drink. 

Do not swap apple cores, candy, chewing-gum, half-eaten food, 
whistles, bean-blowers, or anything that is put into the mouth. 

Peel or wash your fruit before eating it. 

Never cough or sneeze in a person's face. Turn your face to one 
side and hold a handkerchief before your mouth. 

General. — Reports from the sanatoria would indicate that the 
child over four years of age afflicted with tuberculosis in the incipient 
stage has a better prognosis than the young adult. This is borne 
out by our own dispensary cases which have had but in different oppor- 
tunities, and still have shown gratifying results. 

The diet for these children should consist principally of milk, 
eggs, and fats; such as butter, cream, olive or cod-liver oil, and meat 



TUBERCULOSIS. 365 

for older children. The syrup of the iodid of iron should be given. 
If the appetite fails a change from inland to seashore or vice versa 
may be proposed, or if this is not feasible the tincture of nux vomica 
with the compound tincture of cardamon can be given before meals. 
Medication directed to the disease itself is useless and often harmful. 
In hopeless cases the symptoms are alleviated as they arise. 

The tuberculin treatment is again being tried in children's hos- 
pitals and with more success. Good results are obtained in localized 
conditions and some cases having pulmonary involvement have been 
benefited. The former unsatisfactory results are attributable to our 
meager knowledge of its action, and probably to overdosage, which 
seemed to produce harmful results. 

Children in whom the disease seems to be arrested, as shown by 
absence of temperature and increase in weight, are especially suitable 
for the tuberculin treatment. The injection in these quantities may 
be given twice a week until a tolerance is reached when the dosage 
may be slowly increased by 0.1 mg., depending upon the effect produced. 
T2"0"o"o" "t^ ■8TO"o' ^ig- ^^ T. R. tuberculin is given to a child one year old. 
-^--^ mg. for a child five years old. -roVo- i^^g- ^o^ ^ child ten to twelve 
years old. Its effect on the opsonic index should be watched, and a 
dose given every two weeks. If obtaining the opsonic index is not 
feasible, the weight and general progress of the child must act as guides. 



SECTION VII. 
DISEASES OF THE RESPIRATORY TRACT. 



CHAPTER XXV. 
DISEASES OF THE UPPER RESPIRATORY TRACT. 

Acute Rhinitis. 

This is quite commonly seen in infants and children, and is due to 
bacterial infection as a result of a temporary or prolonged lowered 
resistance. This is made possible by keeping the child in superheated 
apartments, sudden changes of temperature, or exposing it to direct 
infection from a member of the household. There is at first a constant 
serous and later mucopurulent discharge from the nares, with irri- 
tability, restlessness in sleep, loss of appetite, and a slight temperature. 

In infancy the symptoms are of greater import than in childhood, 
as it may seriously interfere with nursing and thus add to the lowered 
resistance through malnutrition. Sleep is broken, feeding rules are 
interfered with and disturbances of the gastrointestinal tract may re- 
sult. Older children complain of fullness in the head and chilliness. 
Children who have frequent attacks of rhinitis are ofttimes. sufferers 
from adenoids. 

Treatment. — While rhinitis is a self-limited disease, lasting from 
one to two weeks, it should not be left untreated. The infection may 
spread to the lower respiratory tract and end disastrously. If pos- 
sible, remove the indirect cause, as, for example, badly heated and 
unventilated rooms. The child is best confined to one room, especially 
if there are other children. Locally liquid albolin with camphor gr. i 
to the ounce may be instilled into the nose. A solution of adrenalin 
chlorid 1 to 5000 in infants and 1 to 1000 in older children gives tem- 
porary relief before suckling and at bedtime. Morse found it neces- 
sary to introduce a small rubber catheter into each nostril in a serious 
case to enable it to breathe. Small supportive doses of strych- 
nia o-io^ t.i.d. are sometimes necessary to assist the child in ridding 
itself of the infection. The ears should be examined daily, as an otitis 
is very likely to supervene by extension. 

Epistaxis. 

Bleeding from the nose is not often seen in infants, although not 
uncommon in children; when it occurs in infants it is usually a result 

366 



DISEASES OF THE UPPER RESPIRATORY TRACT. 367 

of adenoidS; syphilitic rhinitis, or an ulceration of the nasal mucous 
membrane, commonly found on the anterior and inferior portion of the 
septum. Children are liable to nose-bleed because of their tendency to 
acquire turgidity of the nasal mucous membrane. Traumatism, ade- 
noids, foreign bodies, and purulent rhinitis are among the more common 
causative factors, while a nose-bleed is also seen in the course of many 
of the infectious and blood diseases of early life. A history of frequent 
epistaxis should lead one to think of and examine for adenoids, ulcers, or 
cardiac disease. 

Treatment. — Keep the child in the upright j30sition and supply 
pressure with the fingers against the septum, meanwhile having an ice 
application held over the cervical spine. If bleeding still persists 
pack the nose with cotton which has been dipped in a 1-2000 adrena- 
lin solution. 

As soon as feasible, make a careful examination for the underlying 
cause. If an ulcer, cleanse and apply a 20 per cent, solution of nitrate 
of silver. If adenoids are present, they must be removed; this is 
especially true in infants who have frequent nose-bleed. Warning 
should be given the attendant as to the significance of swallowed 
blood from a nose-bleed, which may occasion unnecessary alarm when 
vomited. 

Foreign Bodies in the Nose. 

In children, usually between two and five years, it is not uncom- 
mon to find that they have placed various objects in their noses. These 
may cause immediate symptoms of annoyance or distress or, becoming 
lodged, cause a unilateral nasal discharge that is persistent. Closer 
examination shows a partial or total occlusion of that side of the nares, 
a mucopurulent discharge, occasionally blood-tinged, and, with 
some objects, an odor of putrefaction. We have removed peas, 
pearl buttons, shoe-buttons, paper, and a kernel of corn. 

Treatment. — Place the child in a good light and use a small 
nasal speculum. The object if in situ for some time may be coA^ered 
by mucous membrane or altered in appearance so as to be unrecogniz- 
able. If there is still doubt, a probe slightl}-- bent can be inserted 
and the obstruction recognized; wipe out the discharge and with a 
nasal forceps, snare, or hook remove it. If the object has been recently 
inserted and is not high up, causing the child to sneeze by tickling 
the opposite side has succeeded easily in effecting its dislodgment. 
The rhinitis induced clears up rapidly after the offending material is 
removed. 



368 



DISEASES OF CHILDREN. 



Examination of the Throat in Infants. 

A careful inspection of the throat should be made as part of the 
routine examination of the sick infant. Many attacks of fever and 
illness in infants are due to inflammation of the throat, such attacks 
being not infrequently attributed to 
some other cause. The principal reason 
for such a possible error lies in the diffi- 
culty in getting a satisfactory view of 
the fauces. This is especially true in 
very young infants. The tongue is high 
and the soft palate and pillars of the 
fauces low down, so that it is extremely 
difficult to get a clear view of the parts. 
Unless a satisfactory view is obtained at 
the first attempt it becomes increasingly 
difficult, if not impossible, to see clearly 
at all. The opening is so small that a 
little mucus produced by the irritation 
of a second or third examination com- 
pletely obstructs the view. In addition 
to this some milk is apt to be regurgitated 
from the stomach, and then it is abso- 
lutely impossible to see the real condi- 
tion of the mucous membrane. 

The writer has had such difficulty 
at times in satisfactorily examining the 
throat in young infants that he has de- 
vised a tongue depressor for this purpose 
(see Fig. 101). Most of the tongue de- 
pressors in use are not only too large, but 
do not have the proper slant for the 
infant's tongue. As a result, the back 
of the tongue, not being properly held, 
arches up and obstructs the view of the 
fauces. The depressor here presented is 
small enough for the youngest infant's 
mouth, and is intended to curve over 
the tongue to the base of the epiglottis. 
It can likewise be used in older subjects. By exercising a little 
pressure downward and forward the parts will come into clear 
view. Of course the infant should be properly held and placed before 




Fig. 101. — Chapin's tongue 
depressor (straight). 



DISEASES OF THE UPPER RESPIRATORY TRACT. 



369 



a good light (Fig. 103). When everything is in readiness the left 
hand is used to steady the head while the right hand manipulates 
the depressor. These details will naturally suggest themselves to the 
careful physician but are often overlooked, with the result of unduly 
fretting the infant and failing in the examination. 

Pharyngitis and Tonsillitis in Infants. — In infants, tonsillitis, as 
distinct from jjharyngitis, is rare. The whole mucous membrane 
of the pharynx and tonsils is involved in the inflammation. The 
tonsils may be somewhat enlarged and are covered with very fine pin- 
head j)oints of a whitish exudation. These points can be recognized 
only when the fauces are well exposed in a good light. In rare instances 




Fig. 102. — Chapin's tongue depressor (curved). 



the uvula is swollen and infiltrated. The secondary forms of pharyn- 
gitis seen in most infective diseases will not be here considered. The 
primary form is apt to be overlooked from the absence of symptoms 
referable to the throat, and the inability of the infant to call attention 
to the affected part. The swelling of the lymph-glands of the neck, 
so often noted in diphtheria and scarlatina, is not usually present in 
primary pharyngitis. The two most common predisposing causes of 
primary throat inflammation in infants are: (1) disordered stomach 
and (2) exposure to cold. The frequent mistakes in the feeding of 
infants, especially overfeeding, produce an acid fermentation in the 
stomach. By direct continuity the mucous membrane of the pharynx 
and mouth may become irritated and inflamed. When the latter 
happens the temperature keeps up instead of subsiding when the 
stomach is relieved of its contents by vomiting or by their passage 
into the bowel. Exposure to cold is likewise a common predisposing 

24 



370 



DISEASES OF CHILDREN, 



cause. Many infants, especially among the poor, are too warmly 
clad, especially about the neck and chest. As a result the skin is 
constantly moist. Such infants live and sleep in overheated rooms. 
In these cases an ordinary exposure to the cold air of draughts will 
induce throat inflammation. 

It will be noticed that the causes here given are mentioned as 
predisposing. Most, if not all, forms of tonsillar and pharyngeal 




Fig. 103. — Method of holdino; infant for examination of the throat. 



inflammation are due to the presence of microbes. In health and 
under good hygienic conditions the mucous membrane of the throat 
may not be unfavorably affected by microbes, but under depressing 
conditions, particularly when the digestive tract is in an irritated 
condition, the throats of infants are vulnerable. It is quite possible 
that many impurities may likewise find their w^ay to the mouth and 
throat by means of dirty fingers or objects which are given to infants 
as toys and which quickly find their way to the mouth. 



DISEASES OF THE UPPER RESPIRATORY TRACT. 371 

Treatment. — The treatment consists in removing the cause, 
whether it be a deranged stomach, defective action of the skin, or 
faulty hygienic surroundings. The recurrence of attacks of pharyn- 
gitis in infants is the. most common cause of postnasal rhinitis in 
children. The repeated irritation induced by these attacks causes 
hypertrophy of the adenoid tissue at the vault of the pharynx which 
is the invariable accompaniment of rhinitis in the later years of 
childhood. 

The immediate treatment consists in opening the bowels with a 
mild laxative, such as castor oil or calomel, followed by small and 
frequent doses of tincture of aconite, one-quarter to one-half a drop 
every two hours. If restlessness is a prominent symptom, a grain of 
phenacetin may be given every three hours for a few doses. As the 
acute form of the disease is self-limited, it is not well to give drugs 
very freely, especially those that tend to upset the digestion. The 
importance of recognizing the condition consists in taking steps to 
prevent its recurrence. 

Acute Pharyngitis. 

Definition. — An acute inflammation of the pharynx and neigh- 
boring structures. 

Etiology. — Sudden exposure to inclement weather which is dust 
and germ laden predisposes to the affection. It is present in the 
early stages of many of the acute infectious diseases and may accom- 
pany gastric disorders. Exposure to chemical irritants in the form of 
vapors which produce a pharyngitis. Children with obstructions in 
the respiratory tract, especially adenoid growths are liable to repeated 
attacks. 

Symptomatology. — Locally there is seen a reddened congested 
pharynx with the uvula and tonsils sharing in the inflammatory 
process. The larynx and nasopharynx may also be involved. There 
may be a rise of pulse and temperature, but this is rarely high. The 
child complains of sore throat and difficulty in swallowing. Under 
appropriate treatment there is a rapid subsidence of symptoms. 

Diagnosis. — With high temperature and vomiting scarlet fever 
must be kept in mind. Measles will show the presence of Koplik's 
spots, while a diphtheritic process will show a beginning membrane 
and give a positive culture. 

Treatment. — Prophylactic treatment resolves itself into the re- 
moval of any obstructions to proper breathing and the maintenance of 
proper resistance against infections. 

Locally. — Cold compresses applied every half-hour. Mild anti- 



372 DISEASES OF CHILDREN. 

septic gargles for older children, such as the Liq., antisepticus alka- 
linus N.F. or Dobell's solution, one part to eight of water will suffice 
if used every two hours. 

Constitutional. — An initial laxative, such as the citrate of magnesia 
or calomel, should be prescribed. If there is high temperature and 
much discomfort phenacetin with salol 2 grains of the former to IJ 
grains of the latter for a five-year-old child will be efficacious. The diet 
should consist of cool demulcent preparations, such as oatmeal or 
barley gruel, junket or ice-cream. 

Acute Follicular Tonsillitis. 

(Acute Amygdalitis.) 

This is a self-limited disease of short duration, usually bilateral, 
with constitutional symptoms and a marked local infective process 
involving the tonsillar crypts and the entire glandular structure. 

Etiology. — Children with rheumatic tendency or of a strumous 
type are prone to acute attacks; those with chronically enlarged ton- 
sils being particularly susceptible. In these latter cases, slight exposure 
to cold often brings on an attack. One infection predisposes to a 
second, presumably because of the presence of bacteria in the crypts 
or their accessibility to the tonsil through the mouth and nose. 

Symptomatology. — The onset of tonsillitis is sudden; a chill or 
chilly sensations often being the first evidence. This may be followed 
by marked prostration, malaise, and vomiting. The temperature 
is high, frequently rising to 104° or 105° F. At first the tonsils and 
soft palate are reddened and swollen, and in a few hours cream-colored 
isolated spots appear on the tonsil plugging the mouths of the crypts. 
These spots are about the size of a pin-head, though at times they 
coalesce, forming a pseudomembrane which can be easily wiped off 
with a swab without producing a denuded or bleeding area. The 
membrane does not spread to the soft palate nor to the pillars of the 
pharynx. 

Frequently the glands at the angle of the jaw are enlarged and 
these together with the inflamed tonsils produce considerable dis- 
comfort and pain on swallowing. A routine examination of the 
throat in all cases will often disclose a tonsillitis which has produced no 
subjective symptoms. 

Course and Prognosis. — The inflammatory condition is active for 
at least three or four days even under treatment, but because of the 
constitutional symptoms convalescence may be slow; ten days usually 
elapsing during this stage. The prognosis is good if the patient is well 



DISEASES OF THE UPPER RESPIRATORY TRACT. 373 

cared for, though the danger of endocarditis and the possibility of peri- 
tonsillar abscess must not be forgotten. 

Differential Diagnosis. — At the onset, tonsillitis may be confounded 
with malaria, pneumonia, scarlet fever, or influenza. A careful his- 
tory and blood examination will usually eliminate the first; a careful 
physical examination and absence of disturbed pulse-respiration ratio 
would differentiate it from pneumonia, while further observation for 
twenty-four hours will render the diagnosis more certain on account 
of the more characteristic appearance of the tonsils. From diphtheria, 
the absence of Klebs-Loeffler bacilli, the sudden onset and initial chill, 
the position and character of the local lesion, the high temperature 
and the absence of a histor}^ of exposure to diphtheritic infection point 
strongly to the diagnosis of follicular tonsillitis. (See Plate XI.) 

In ulceromembranous tonsillitis, the constitutional symptoms 
are much milder; the pain in the throat more severe, and enlargement 
of lymph-glands more marked. The local lesion is usually one-sided, 
the affected tonsil being covered with a dirty yellowish exudate 
closely resembling the membrane of diphtheria. 

Treatment. — Rest in bed is imperative on account of the great 

danger of endocarditis. Depletion by calomel gr. y^ every half-hour 

for ten doses will reduce the intoxication. Hot fomentations or cold 

compresses to the throat will give relief from pain. Alcohol sponge 

baths when the temperature is high will add materially to the comfort 

of the patient. During the first twelve to twenty-four hours the 

following may be given to a child two years old. 

I^ Phenacetini gr. ^ 

Salol gr. j 

Oleosacchari anisi, q.s. 

M. Ft. pulv No. j 

Misee et signa. — One every three hours. 

For young children w^ho have not learned to gargle, a very effi- 
cient local application to be used on a swab every two or three hours 
is the following: 

I^ Tincturse iodini ttj^ iv 

Argyrol gtt. iij 

Aquae q.s. ad. 5ss 

Misce et signa. — Swab on tonsils every two to three hours. 

Older children may gargle with the Liq. antiseptic, alkalinus (N.F.) 
or any of the equally efficient mild antiseptic solutions. 

Ulcero-membranous Tonsillitis. 

{Vincent's Angina.) 
Clinically, this affection closely resembles a mild diphtheria; 
bacteriologically, the findings show the presence of an elongated 



374 DISEASES OF CHILDREN. 

fusiform bacillus and long wavy spirilli. The general symptoms are 
mild or absent except for the pain in the throat which is severe. 

The lesion is a superficial ulcer on the tonsil the size of a dime, 
usually unilateral in location, of a dirty yellow color, and exhibiting 
no great tendency to spread. If the ulceration is deep, upon an 
attempt to pull off the membrane the underlying surface bleeds 
slightly. The cervical glands are enlarged and the muscles along the 
side of the neck are stiff and tender. The pulse and temperature are 
moderately increased, the latter closely resembling the temperature 
in diphtheria. 

As a rule, the breath is foul and there is much drooling. Hot 
antiseptic gargles and mildly astringent applications (see p. 373) 
locally combined with hot or cold external applications are very 
efficient measures of relief. 

The disease runs much the same course as a follicular tonsillitis. 
A smear and culture should be made in all suspicious cases for purposes 
of differentiation. 



Chronic Tonsillar Hypertrophy. 

A condition of chronic enlargement of the tonsils is seen in many 
children giving a history of repeated attacks of tonsillitis, or as a 
result of the infectious diseases. Adenoid vegetations and hyper- 
trophied tonsils are associated in many cases. 

Symptomatology. — There is impaired phonation and the train of 
symptoms which are associated with adenoids, the distress being 
especially produced at night during sleep. Restlessness and snoring 
are more marked. 

Treatment. — Chronic enlargements should be removed. For 
children the guillotine is preferred, a size suitable for the patient 
being selected. 

Cocain as an anesthetic should not be used. If adenoids are 
present remove the tonsils first. In unruly children an anesthetic 
is necessary, and the child should be prepared as for the adenoid 
operation. 

The head may be slightly raised and the assistant should gently 
press the tonsils from the outside, toward the middle line. The 
results obtained do not seem to warrant complete excision with special 
instruments as has been advocated by some throat specialists, but 
complete enucleation with the finger is often desirable and produces 
less traumatism. 



DISEASES OF THE UPPER RESPIRATORY TRACT. 6iD 

Adenoids. 

(Hypertrophy of the Pharyngeal Tonsil.) 

This term is applied to a hypertrophy of the lymphoid tissue 
normally found in the pharyngeal vault. 

Etiology. — Adenoids are found at all ages and are far from 
infrequent in infants. Children who have lived in a poor hygienic 
environment or whose parents have chronic diseases seem to inherit a 
tendency to adenoids. They are usually associated with enlargement 
of the faucial tonsils. • Rickets and the condition known as the 
lymphatic diathesis predispose to adenoid vegetations. . Kerley 
believes that the pernicious use of the so-called comforter with the 
constant sucking is directly productive of adenoids. 




Fig 104. — Typical adenoid face. 



Symptomatology in Infants. — The symptoms differ considerably 
in infants, and therefore will be described separately. The babe may 
be brought because it cannot suckle without frequently stopping to 
breathe through its mouth. Sleep is broken and the infant cries and 
almost chokes when it drops into a deep sleep. A persistent rhinitis is 
commonly observed, and sniffling may be the most prominent symp- 
tom. The expression is not changed as in older children. 

In Children. — In early cases the child is brought for examination 
because of frequent "colds in the head" associated with troubled sleep 



376 DISEASES OF CHILDREN. 

and snoring. In more aggravated conditions, mouth-breathing, 
snoring at night with tossing, restless sleep, and occasional night 
terrors should lead to a careful nasopharyngeal examination. In 
typical cases, the vacant expression, fish-like face, and open mouth, 
often with a high arched palate, are readily noted. The face in these 
mouth-breathers has been visibly deformed (Fig. 104), and the following 
characteristics make the diagnosis simple: partly pursed mouth, pro- 
truding lower jaw; narrowed long face; V-shaped palate; enlarged 
tonsils; narrow alse nasi; dull eyes; pale mucous membranes; narrowed 
chest, sometimes otitis and evidences of general malnutrition. These 
children have a nasal twang to the voice and are poor scholars. They 
tire easily, do not eat well, and may suffer from incontinence of urine. 
There may be partial deafness from obstruction of the Eustachian 
tube. If a granular pharyngitis with plugs of mucus hanging from 
the posterior nares is observed, adenoids are usually present. A 
useful test generally indicating nasal obstruction due to adenoids is to 
request the child to repeat the words ^'clapham common" which he 
cannot enunciate without a nasal twang. 

Examination. — In infants it is a difficult procedure, but may be 
occasionally accomplished with care and patience; the little finger must 
be used for exploration as the space is so small. In older children 
the finger properly protected should be passed into the nasopharyngeal 
space and the amount and character of the adenoid tissue appreciated. 
Soft pendulous masses or firm growths may be felt and, if the vault is 
found to be occluded with hypertrophied tissue, operative interference 
should be resorted to. Occasionally it is necessary to give a whiff of 
chloroform before the examination can be made, or this can be deferred 
until ready to operate. 

Treatment in Infants. — If the symptoms of obstruction are such 
as to interfere with the infant's nutrition, the adenoids should be 
carefully and completely removed by an expert. Palliative measures 
are ofttimes successful in less aggravated cases, and we have found 
the instillation of a mixture such as the following to be of benefit : 

I^ Camphorse gr. j 

Menthol gr. j 

Resorcini gr. ij 

Benzoinol oj 

Misce et signa. — Five drops every three hours into the nose with a 
medicine dropper. 



or 



I^ AdrenaHni inhalantis oss 

Liquidi albolini q. s. ad oss 

Misce et signa. — A few drops in nose, night and morning. 



DISEASES OF THE UPPER RESPIRATORY TRACT. 377 

In Older Children. — Palliative measures here are useless. The 
operation should be performed under a general anesthetic if there are 
no contraindications, such as bronchitis, acute tonsillitis, etc. The 
adenoids, and if present, the enlarged tonsils are removed at the 
same time. The after-treatment is to break up the habit of mouth- 
breathing by careful instructions in proper breathing and corrective 
exercise. (See page 96.) 



Peritonsillar Abscess. 

(Quinsy.) 

A retropharyngeal abscess is more common in infancy than peri- 
tonsillar abscess. Older children, however, have abscess formation in 
the peritonsillar tissue, accompanied by fever, chilliness, and difficult 
swallowing. The mouth is opened with difficulty and the tonsil on one 
side is seen to bulge forward. The finger ehcits fluctuation when the 
condition is at its height. 

Treatment. — In the early stages calomel or effervescent citrate of 
magnesia may be given for the bowels. Salol and phenacetin, one and 
a half grains of each, may be given every three hours for a five-year- 
old child. Cold milk sucked through a tube is agreeable and keeps 
up nutrition. Incise with a guarded scalpel, and drain as soon as a 
diagnosis of an abscess is made. A gargle and occasional digital 
pressure for evacuation of the pus made over the affected site serve 
to prevent reinfection. 

Retropharyngeal Abscess. 

This abscess is seen not rarely in infants and children below the 
age of two years. Ill-nourished children are more prone to it because 
of their lowered vitality, and infection takes place from the organisms 
commonly found in the mouth. 

Symptomatology. — The infant is usually brought for examination 
because of difficulty in breathing. In the early stages there is mainly 
an inspiratory dyspnea, but as the abscess grows larger difficulty is 
experienced both in inspiration and expiration. During sleep there 
is a persistent rattling snore and the child frequently awakes to 
change its position. The child refuses nourishment or takes it 
with great difficulty. The temperature is irregular and fluctuates 
from 100° to 103° F. When the head is bent forward, the dyspnea is 
increased. 



378 DISEASES OF CHILDREN. 

Inspection with a suitable tongue depressor will show a rounded 
reddened mass protruding almost from the center or on one side of the 
pharyngeal wall. The examining finger detects fluctuation. 

Treatment. — It is imperative that the abscess be opened and 
thoroughly drained. The child's head should be held well forward 
and then downward when the abscess has been opened to prevent as- 
piration of the pus. Strychnin and whisky are usually indicated to 
combat the septic absorption. In a few of our cases it has been neces- 
sary to feed the child by gavage for a few days following the evacuation 
of the pus. 

Acute Laryngitis. 

(Spasmodic Croup; Spasmodic Laryngitis; False Croup; 
Catarrhal Croup.) 

Etiology. — This is usually due to bacterial infection made possible 
by sudden exposure to cold or wet. It is most commonly met with 
from the second to the fifth year of life and is apt to recur. Laryngitis 
occasionally antecedes the eruption in measles. Children with naso- 
pharyngeal obstructions are predisposed to the affection. 

Symptomatology. — The attacks usually come on in the evening 
or at night. The child has appeared to be quite well during the da}'^ 
and no symptoms have been observed except a slight rhinitis. With- 
out warning a croupy harsh and brassy cough develops, accompanied 
by loud croupy breathing, heard with inspiration, expiration being 
quite noiseless. The patient is alarmed and the sleep is restless. 
The cough thoroughly alarms the mother and her fright is communi- 
cated to the child. In severe attacks the patient must sit up in bed to 
breathe; the suprasternal notch and diaphragmatic groove are re- 
tracted. After the attacks the child is exhausted and wet with per- 
spiration. There may or may not be any temperature. The attacks 
even if uninfluenced by treatment, subside toward the morning 
hours, the harsh breathing ceases, and the child quietly rests. On 
the succeeding day the patient is ready to play and the cough while 
present is not annoying. For several nights there will be a repetition 
of the dyspnea and croupy cough. 

Diagnosis. — Laryngeal diphtheria must be excluded. In diph- 
theria the breathing slowly becomes worse with no remissions. The 
constitutional symptoms are more marked and the inspiratory 
stridor may be present without the croupy cough. Seek safety in a 
culture, and if the weight of evidence leans toward diphtheria give 
antitoxin. 



DISEASES OF THE UPPER RESPIRATORY TRACT. 



379 



Differential 

Acute Laryngitis. 
Sudden onset. 
Dyspnea intense from start but 

evanescent. 
Cough resonant and brassy 

(barking). 
Voice, usually normal. 

Inspiratory stridor. 
Albumin rarely in urine. 
No membrane seen. 



Diagnosis. 

Diphtheritic Laryngitis. 
More gradual invasion. 
Dyspnea slowly but progressively 

worse. 
Cough muffled and suppressed. 

Voice muffled and almost lost. 
Inspiratory and expiratory stridor. 

Inspiratory more marked. 
Albumin commonly found. 
Membrane may be seen in pharynx 

and tonsils or coughed up. 



For differential diagnosis, from Laryngismus Stridulus, see p. 381. 

Retropharyngeal abscess will be differentiated b}' the increase 
in dyspnea when the head is dropped forward and by directly palpat- 
ing a fluctuating mass. 

Prognosis. — Distinctly favorable, never fatal, but recurrences 
are common. 

Treatment. — Place the child in a warm, moist room. In mild 
cases an emetic dose of the wine of ipecac, half a dram every 
half-hour until vomiting ensues, may be sufflcient to give relief. A 
warm mustard bath aids the result. An enema should be ordered if 
the bowels have not recently moved. In severer cases a croup tent 
(see page 380) should be made over the crib and a croup kettle 
started in which has been placed a dram or two of the compound 
tincture of benzoin. Emesis should be brought about as rapidly as 
possible. Antipyrin gr. 3 for a three-j^ear-old child acts as an anti- 
spasmodic. If there is cyanosis and serious obstruction intubation 
may be necessary, however a smear and culture should be made in 
these cases to exclude diphtheria. 

The succeedijig day should be spent quietly, a light diet given and 
the bowels kept open. If there are adenoids present, these should 
be removed at a later date. 



Edema of the Glottis. 

(Submucous laryngitis.) 
Definition. — This is an infiltration of serum into the submucous 
layer of the glottis and the neighboring aryepiglottic folds. 

Etiology. — Serous infiltration may result from the irritative 



380 



DISEASES OF CHILDREN. 



action of corrosive drugs accidently swallowed, from foreign bodies, or 
it may occur during the course of nephritis, syphilis, the infectious 
diseases, streptococcic inflammation of the larynx or its neighboring 
structures by extension. It occasionally occurs in severe cardiac 
affections and with extensive edema of the lungs. Tumors, such as 
papillomata, have produced the condition. The angioneurotic 
type of edema of the glottis is extremely rare. 




Fig. 105. — Croup tent. 



Symptomatology. — The striking symptom is the inspiratory dysp- 
nea which results. There is usually some stridor and a muffled voice. 
Pain and dysphagia are present when the edema is the result of a 
local inflammation resulting from trauma, hot steam, acids, etc. 

Inspection shows an engorged mucous membrane, swollen epiglot- 
tis, and narrowed rima glottidis. The folds of mucous membrane may 
overhang the glottis. The edema may be felt by the finger or seen by 
the laryngeal mirror. 

Course and Prognosis. — The course and prognosis are directly 
proportionate to the severity of the underlying disease or to the 



DISEASES OF THE UPPER RESPIRATORY TRACT. 381 

amount of trauma that has been caused. Unreheved cases of edema 
of the glottis often terminate fatally. The milder types due to the 
infectious diseases and kidney disease improve with the amelioration 
of the primary cause. 

Treatment. — In mild cases attention should be directed principally 
to the underlying disease. Diaphoretics and diuretics are distinctly 
helpful. Dover's powders will allay pain and restlessness until more 
heroic measures are taken. Scarification is occasionally successful 
in giving relief when performed by a specialist. Tracheotomy is to 
be preferred to intubation in desperate cases when suffocation is 
imminent. 



Laryngismus Stridulus. 

Laryngismus stridulus is a neurotic disease of infancy, charac- 
terized by spasmodic attacks affecting the glottis and the neighboring 
laryngeal muscles. 

Etiology. — Rachitic infants and those with adenoids are especially 
predisposed. Exposure to irritating gases or vapors, or badly ven- 
tilated apartments may bring on an attack. 

Symptomatology. — This varies with the severity of the disease 
and with the particular spasm. In some cases the spasm is but 
momentary ending with an inspiratory crow; again it may recur every 
few moments with but slight inconvenience to the patient. In severe 
attacks the crowing inspiration is distinctly audible, the infant 
becomes spastic, and the efforts to breathe are marked. Lividity 
of the face and a gasping expression are observed. Carpopedal 
spasm and in some instances convulsions follow severe attacks. In 
the intervals the breathing may be quite free and unobstructed, with 
no constitutional symptoms. Fatal cases are rare, but have been 
reported. 

Laryngismus Stridulus. Spasmodic Croup. 

(Acute Laryngitis.) 
Ill-nourished infants under two Commonly from two to five years. 

years. 
No pyrexia. Some pyrexia, 

No cough or rhinitis. Brassy cough and coryza. 

Attacks momentary and recur Attacks usually at night, last 
often. longer and have longer periods 

of remission. 



382 DISEASES OF CHILDREN. 

Treatment. — In the severe cases, emesis with wine of ipecac in half- 
dram doses every half-hour until vomiting ensues may be employed, 
with cold sponging of the face and chest. A cleansing enema in a 
badly-fed rickety infant is often effectual. The underlying cause 
must be removed or combated in the interval. Adenoids should be 
removed, and the infant placed on a properly proportioned diet. This 
alone is curative in certain babies fed on the proprietary foods. A 
quiet atmosphere and a well-regulated dietary will cure the majority 
of cases. 

Congenital Laryngeal Stridor. 

{Congenital Infantile Stridor. Thymic Asthma.) 

This congenital condition is rare and is often confused with 
laryngismus stridulus. 

Etiology. — There is still confusion as to the causation. One 
theory is that it is due to a poorly coordinated action of the respira- 
tory muscles involved in the act of breathing. The epiglottis is 
deformed as a result, and inspiration then produces the peculiar crow- 
ing respiration of the affection. (Thomson.) 

Sometimes a narrowed, infolded and thinned-out epiglottis is 
found which can be observed by laryngoscopic examination to cause 
the peculiar sounds. Variot claims that the condition is found in the 
lymphatic diathesis and that it is caused by an enlarged thymus, 
his observations being confirmed by X-ray examinations. Others 
believe it to be a pure neurosis dependent upon an underlying nutri- 
tional defect. 

Symptomatology. — From birth there is heard mainly on inspira- 
tion a high-pitched rasping croak; with expiration this is heard only 
with difficulty or not at all. Crying or excitement of any kind 
increases the stridor and even retraction of the thoracic spaces. On the 
other hand, it is rarely audible during quiet sleep. The voice is not 
affected even in crying. There is no cyanosis produced by obstruction. 

Diagnosis. — This is founded upon the inspiratory stridor present 
since birth in a child otherwise unaffected as to development and who 
is not made sick or uncomfortable by the condition. Laryngoscopic 
examination or a direct examination of the epiglottis can be quite 
often made in infants with a correctly-shaped tongue depressor. 
Laryngismus stridulus (p. 381) is found mainly in rachitic children, 
is rare before the dentition period, and is often associated with 
tetany. New growths of the larynx should be ruled out by careful 
examination. 



DISEASES OF THE UPPER RESPIRATORY TRACT. 383 

Course and Prognosis. — Up to the end of the first year the condi- 
tion is at its worst; then ameUoration begins and at the second year 
it quite disappears. The physical condition is not affected, but super- 
added diseases of the respiratory tract are apt to have a fatal issue. 

Treatment. — The condition does not lend itself to any form of 
treatment, but the intubation tube and instruments for tracheotomy 
should be on hand if any respiratory disease complicates it. 

New Growths of the Larynx. 

Papillomata. — Although by no means common, they are not 
rare. They may be congenital or attributed to the specific fevers. 
Distinct continued hoarseness is the prominent symptom. As the 
growth later on causes obstructive symptoms, dyspnea or suffocative 
attacks follow. The diagnosis may be made or confirmed by the use 
of the Killian's tube (bronchoscopy). Intubation may be practised 
for immediate relief and then an endolaryngeal operation may be per- 
formed. If this is not feasible, tracheotomy must be resorted to. 
Fibromata are rarely seen in early hfe. 



CHAPTER XXVI. 
DISEASES OF THE LUNGS AND PLEURA. 

Acute Bronchitis. 

This is an acute inflammation of the mucous membrane of the 
large and medium-sized bronchi. It is a frequent disease in early hfe. 

Etiology. — Bronchitis results as an infection following lowered 
resistance from exposure, malnutrition, rickets, enlarged tonsils, 
adenoids, valvular disturbances, or following the infectious diseases. 
Irritating gases or dust particles may also cause a form of bronchitis. 
The bacteria found in the secretions are many and varied and of the 
types commonly found in the bronchial tract. 

Symptomatology. — The symptoms usually begin with a coryza, 
or follow an obstinate rhinitis or tracheitis. There is a hard, dry cough 
which soon becomes loose as more mucus is produced. The pulse and 
temperature are slightly elevated, rarely over 101° F. during the day, 
but may be a degree or two higher in the evening, while the respirations 
are always higher than normal. The child, as a rule, does not com- 
plain and may be quite willing to be about; infants, however, are often 
restless and irritable and vomiting may result from an attack of 
coughing. The stools are rarely normal, either constipation or loose 
stools being observed. It must be recollected that the sputum is 
swallowed by infants and children up to five years of age. The 
disease tends to recovery in from five days to a week. Severer forms 
are seen which are due to involvement of the smaller bronchi (formerly 
termed capillary bronchitis) in which the symptoms are more pro- 
nounced and there is some dyspnea. The pulse and respiratory 
ratio may be somewhat disturbed and a pneumonic process result 
from infection of the alveoli. 

Physical Signs. 

Inspection. — Breathing is quickened, and there may be recession 
of the softer parts of the chest wall especially in rickety children. 

Percussion. — No changes from the normal. 

Auscultation. — Exaggerated puerile breathing and rales of varied 
character, according to the location of the inflammation, are found. 

384 



DISEASES OF THE LUNGS AND PLEURA. 385 

Large, coarse rales (ronchi) over the larger tubes and moist rales with 
finer rales over the smaller bronchi may be noted. 

Tactile fremitus is often distinct in infants when the secretions 
are viscid. 

Diagnosis. — The differential diagnosis is to be made from broncho- 
pneumonia, in which the temperature is higher with a disturbed pulse 
and respiration ratio, by the grunting respiration and dyspnea. 
The physical examination does not elicit dullness and subcrepitant 
rales as in pneumonia. In pulmonary collapse there is dullness on 
percussion and absence of respiratory murmur and subnormal 
temperature. 

Prognosis. — This is usually good except in cases of rickets and 
after the infectious diseases, w^hen pneumonia is likely to follow. 
Young infants, however, may die from a simple bronchitis when the 
tubes become obstructed with mucus followed by cyanosis. 

Treatment. — Rest for the patient and fresh air are necessary 
requirements. A change to a different climate will often alone effect 
a cure. The bowels should be opened with a grain of calomel in divided 
doses or one or two drams of castor oil. The diet is to be restricted 
and water freely given. If the temperature is unduly high and is 
causing discomfort, an alcohol rub is indicated. The use of hot 
poultices and jackets are mentioned only to be condemned, and the 
same may be said of the so-called syrupy cough mixtures. If the 
secretions are persistently dry and the cough harassing, the Liq. 
ammonia anisatis in 3 to 5 drop doses in water to a child of five years 
or in the following mixture will prove useful, and will not disturb 
the digestive apparatus. 

I^ Liquor ammonii anisatis. 5j 

Potassii iodidi gr. iv 

Glycerini oss 

Aquae qs. ad. o ij 

Misce et signa. — oj every three hours. 



or the aromatic spirits of ammonia in five to ten drop doses, diluted, 
is also effective. 

Do not give muriate of ammonia to children. If at night a sed- 
ative is necessary to allow the child to sleep, appropriate doses of any 
of the following drugs may be given: 

Codein, Tincture opii camphorata, Antipyrin, or Sodium bromid. 

The room is to be kept Avell ventilated and the temperature not 
above 70° F. An enforced rest in bed with no further treatment than 
a, free catharsis is often alone curative. If the child has adenoids 

25 



386 DISEASES OF CHILDREN. 

and enlarged tonsils, these should be removed at a later date to prevent 
subsequent attacks. 

Chronic Bronchitis. 

Etiology. — This may result from repeated attacks of the acute 
form. Children suffering from disease of the heart, kidneys, or 
liver are prone to pulmonary congestion, and thus acquire a chronic 
bronchitis. 

Rachitic children, those with a tendency to lymphatism and 
adenoids, and those with a tuberculous diathesis are often afflicted 
wdth chronic bronchitis. 

Symptomatology. — Fever is rarely observed and the child is not 
incapacitated from its play. The cough is often mistaken for per- 
tussis and is worse at bedtime and upon arising. Older children 
expectorate an abundant frothy mucoid secretion, while younger 
children may swallow or vomit it. 

The physical signs are more marked when there is an accumulation 
of mucus and almost disappear in the quiescent stage. During the 
warmer months the cough may entirely disappear. 

Diagnosis. — From pertussis the differential diagnosis is made 
by the course and the paroxysmal attacks followed by vomiting. 
Tuberculosis may be differentiated by the recent tuberculin tests, 
the absence of fever, and the physical signs. 

Prognosis. — The prognosis bears a distinct relation to the etiologi- 
cal factor. If this can be remedied, as adenoids for example, much 
improvement may be expected. If there is glandular enlargement 
present or a tuberculous tendency, the outcome is not as hopeful. 

Treatment. — First remove if possible the underlying cause. 
Climatic treatment is often productive of good results. Tonics such 
as the syrup of the iodid of iron and cod-liver oil are serviceable. 
Carbonate of guaiacol in 3 to 5 grain doses in sugar of milk is beneficial 
for the cough. 

Pulmonary Collapse. 

Collapse of small areas of the lung occurs frequently and quite 
t^asily in infancy. The condition may occur in cases of bronchitis 
and in obstruction or stenosis of the upper respiratory tract or the 
bronchi. 

Children with rickets are particularly predisposed, as the condi- 
tion is dependent upon the yielding nature of the thoracic walls in 
early life. 



DISEASES OF THE LUNGS AXD PLEURA. 387 

Symptomatology. — Superficial areas cannot be detected by phys- 
ical examination, nor do they produce any noticeable symptoms. 
Larger areas give rise to very marked and sudden symptoms. The 
chiWs condition suddenly changes to one of cyanosis; his restlessness 
is dependent upon the inability to get air; the breathing is extremely 
shallow and gasping; the supraclavicular spaces show marked recession 
with each effort of breathing. A fatal issue may be preceded by 
convulsions. 

Physical Examination. — Dullness, or dullness to flatness, over the 
collapsed area is noted. On auscultation, the breath sounds are en- 
tirely absent. The crying voice is diminished. Areas of compensatory 
emphysema are present, usually in the upper portion of the chest. 
These signs, with the historj^ of sudden onset, in a child suffering from 
a previous pulmonary condition should cause no confusion in the 
diagnosis. 

Treatment. — A full hot mustard bath followed by artificial res- 
piration may be employed in desperate cases. Holding the infant by 
the heels may succeed in producing an effort at deep inspiration, and 
will dislodge any considerable amount of mucus that may have acted 
as the cause of the collapse. The production of emesis by the intro- 
duction of the finger in the throat should be tried. If the secretions 
are still found to be considerable in amount after amelioration of the col- 
lapse, a hj^podermatic injection of atropin sulphate -^^ gr. will be 
efficacious. A trained attendant should be placed in charge. 

Emphysema. 

Emphj^sema in some degree occurs very frequently in infants 
and children suffering from bronchial affection. 

Acute emphysema occurs most frequently in bronchitis, broncho- 
pneumonia, pertussis, stenosis of the larynx, and pulmonary collapse. 
It is produced by overdistention of the weak elastic tissue of the 
alveoli when the glottis is closed in violent efforts of coughing. 

Children suffering from chronic bronchitis frequently have an 
accompanj^ing empliA'sematous condition which does not recede until 
some time after all evidences of the bronchitis have disappeared. 

This condition of chronic emphysema is not often seen in child- 
hood. The diagnosis is based upon the abnormal^ full and rounded 
chest, the hyperresonant note on percussion, the diminution of the 
area of relative cardiac dullness and the sonorous and sibilant rales 
heard all over the chest with unduly prolonged expiration. 

The prognosis and treatment are mainly those relating to the 
underlying conditions. 



388 DISEASES OF CHILDREN. 

Bronchial Asthma. 

This is a disease not common to early life and is due to a spasmodic 
contraction of the bronchial tubes as a result of some form of patho- 
logical stimulation of the bronchial muscles. 

Etiology. — Salter records 225 cases, among which 11 began the 
first year of life, and 60 as occurring from the first to the tenth year of 
hfe. 

Bronchitis is, in the majority of instances, the predisposing 
disease. Nasal obstructions, especially adenoids, are important 
etiological factors. They were present in 47 per cent, of La Fetra's 
cases. 

Symptomatology. — The attack may begin with a fairly pronounced 
bronchitis which lasts for several days; then there may be suddenly 
superadded dyspnea with its accompanying rapid respiration, anxious 
expression, and rarely cyanosis. 

Inspection of the chest during the paroxysm shows retraction in 
the suprasternal and supraclavicular spaces, and the activity of the 
accessory muscles of inspiration. 

Auscultation. — Sibilant and sonorous rales are heard both during 
inspiration and expiration all over the chest. 

Percussion. — A hyperresonant note is elicited during the height of 
the attack. There is rarely any temperature unless the attack has 
closely followed an acute bronchitis. It rarely rises above 102° F. 

Blood examinations may be of assistance from the standpoint of 
differential diagnosis. Polymorphonuclear eosinophiles are increased 
in number, while in prolonged subacute cases a relatively lower 
eosinophilia is found. 

Treatment. — Adenoids, enlarged tonsils, and other obstructions to 
proper breathing must be removed. Attacks of bronchitis are to be 
guarded against. A careful process of hardening by hydrotherapy 
or a change of environment may be necessary to prevent repeated 
attacks. Careful oversight of the diet must be observed and indiges- 
tion avoided. 

The indication for the treatment of the acute attack is the relief 
of the bronchial spasm. For this purpose a combination of the iodids 
and bromids is of distinct service. The bowels should be emptied with 
a soapsuds enema, and if there is any history of indiscretion in diet, 
an emetic dose of the wine or the syrup of ipecac given. 

Nitroglycerin j^q to y^-Q of a grain, or atropin 5-^-0 of a grain 
for a two-year-old child may be necessary for relief in severe cases. 
The syrup of the iodid of iron is valuable following the attack. 



DISEASES OF THE LUNGS AND PLEURA. 389 

Acute Bronchopneumonia. 

(Lobular Pneumonia, Catarrhal Pneumonia, Capillary Bronchitis.) 

This is perhaps the most common disease of infancy and is very 
often a secondary manifestation. 

Bronchopneumonia occurs most frequently in early life, and is 
secondary to an involvement of the bronchial tubes. 

It is most often met with during the first two years of life, and is 
rarely seen after the sixth year. Bronchitis, the infectious diseases, 
especially measles, pertussis, influenza, diphtheria, and scarlet fever 
are the predisposing causes. Children with rickets, marasmus, 
syphilis, nephritis, and gastroenteritis, especially if they are in bad 
hygienic circumstances, have their resistance lowered, and are thus 
predisposed. Infants in asylums and institutions are especially 
prone to the affection. The pneumococcus of Frankel, Friedlander's 
bacillus, strepto- and staphylococci, and the bacterial flora of the 
nose and mouth are the exciting causes. 

Pathology. — The pneumonic areas result from extension of the 
inflammation through the bronchial walls and from the bronchial 
walls themselves into the peribronchial tissue. Thus not only the 
alveoli to which the bronchial tubes lead are involved, but also those 
which surround the tube. The alveoli become invaded by the 
bacteria and distended with white blood-cells, and contain some fibrin 
and red blood-cells. The small patches soon coalesce and become the 
size of a half-dollar or even in exceptional instances involve the greater 
part of one lobe. On cut section, the bronchioles are found partly 
dilated and a mucopurulent exudate flows out on pressure. The 
bronchial glands at the root of the lung may be infiltrated and an 
increase in the interstitial tissue is found in the older cases. Pleuritis 
is seen with any considerable area of pneumonia. Accumulations of 
fluid, small in amount, are not uncommon at autopsy. The same may 
be said of emphysema, gangrene, and multiple lung abscesses. 

Symptomatology. — There are few diseases in which the symptoms 
may be so varied as in bronchopneumonia. The following descrip- 
tion will show how varied the symptomatology may be, and what wide 
differences are found in the physical signs. The disease may be 
ushered in with vomiting or high temperature. On the other hand, 
fever may be absent or extremely low throughout the disease. There 
usually is restlessness, rapid breathing, and a cough which may be 
severe or scarcely noticeable. If the disease follows, as it usually 
does, an attack of bronchitis^ all the symptoms which were present 
are exaggerated while the breathing becomes labored and the tem- 



390 DISEASES OF CHILDREN. 

prerature increases. The cry is stifled and an expiratory grunt which 
is quite characteristic of acute lung involvement is heard. The pulse 
rate is much increased, rising to 120 or 180, and is small in character. 
The respirations are increased to 60 or 80, and the efforts made to get 
enough oxygen are shown at the peripneumonic groove and by the 
dilated alse nasi. If a considerable portion of the lung is involved, 
cyanosis in the lips or finger-nails is observable. The child feels 
distinctly sick; it may refuse food, but usually takes water eagerly. 
The tongue is dry and coated. The dyspnea increases, and the cough 
may be harassing and suppressed. The pulse becomes weaker, and 
the hands and feet are cold. Sleep is fitful and constantly disturbed 
by efforts to cough. If the disease progresses and the temperature 
remains persistently high, stupor, delirium, or even coma may ensue. 
The pulse may become irregular. The heart action may give indi- 
cations of myocardial changes and convulsions may precede a fatal 
termination. Improvement or retrogression of the affection is shown 
by a decreased number of respirations and a more normal pulse- 
respiration ratio. The character of the pulse improves, the infant 
takes some interest in his surroundings, sleeps more, and finally takes 
nourishment eagerly. 

Physical Signs. — The objective symptoms vary as greatly as the 
subjective signs. The examiner must not be astonished if he finds 
signs not commensurate with the degree of prostration. 

Palpation. — Little or no satisfactory information is obtained. 
However, the apex beat of the heart may be located and pain on han- 
dling appreciated. 

Inspection. — Rapid, labored breathing is noted. The alse nasi 
are dilated, and there may be some degree of cyanosis visible. Re- 
traction of the peripneumonic groove is observed in advanced cases. 

Auscultation. — Auscultation with inspection are of the greatest 
value. A pause between inspiration and expiration occurs, and can 
be appreciated if the child is quiet or sleeping. The bronchitis present 
will be revealed by coarse moist rales, often sonorous in character. 
Subcrepitant and crepitant rales with diminished breathing heard at 
the end of inspiration over a limited area reveal the location of the 
pneumonic involvement. These are best heard when the infant is 
crying or during coughing. The examination should not cease without 
sufficiently forcible respiratory efforts on the part of the infant. 
Prolonged expiration and bronchial breathing are obtained when the 
area of the pneumonia is recent. Vocal fremitus may be heard 
while the child is crying, over larger areas of consolidation. The 
examiner must not fa'l to use a stethoscope with a small bell, and 



DISEASES OF THE LUXGS AND PLEURA. 391 

must not omit in his search the axillary region, for the first signs are 
often found there. 

Percussion. — Light percussion is a desideratum. Dullness may be 
appreciated if present and points to consolidation. Areas giving a 
hyperresonant note are obtained over portions of the lung in which a 
compensatory emphysema has occurred. 

The Important Symptoms in Detail. Temperature. — As a rule, 
the temperature is high in the beginning, 103° to 104° F.^ although 
periods of remission are not uncommon. The disease ends by lysis 
and the curve shows the gradual return to the normal. No typical 
temperature curve can be presented because of the intermittent and 
remittent character of the fever. Sudden high rises may indicate a 
complication or an added area of pneumonia. Marasmic infants 
frequently are seen with little or no fever, or they may even have a 
subnormal temperature. 

Respirations. — The normal ratio of pulse and respirations, 1 to 3, 
or 1 to 4, may be so far disturbed as to reach 1 to 2.5 or 1 to 2. The 
severity of the dyspnea can be judged by the amount of recession at 
the sternal space and diaphragmatic attachments. The breathing 
may be irregular or simulate the Cheyne-Stokes type. Coughing or 
crying markedly accelerates the respirations, and if pain is present it 
is increased. The expiratory grunt is almost pathognomonic. It is 
produced in early life by only three conditions, namely, pneumonia, 
pleurisy, and a very acute indigestion. In rachitic children the 
respirations are especially increased and extremely shallow. 

Heart and Pulse. — The pulse is small and frequent. When the 
temperature is high the pulse may be as rapid as 180 to 200. Its 
numerical value is not of as much moment as the character of the 
pulse compared to the action of the heart. The second sound is often 
accentuated, and anemic murmurs are heard during convalesence. 

Digestive Tract. — Especially to be feared is the distention of the 
abdomen with gas. The meteorism impedes the movements of the 
diaphragm and adds greatly to the discomfort of the infant. Vomit- 
ing is often one of the initial symptoms. Diarrhea is more frequent 
in the nursling, while constipation is the rule with. the artificially fed. 

Occasionally stupor is seen from the first clay of the disease. A 
convulsion may usher in the disease or purposeless movements may 
appear at any time in its course. Meningitis may be in consequence 
suspected. True symptoms of cerebral involvement may precede a 
fatal termination. The ear should be examined in suspected cases, 
and lumbar puncture made for purposes of verification. 

Clinical Forms of the Disease. — Disseminated bronchopneumonia 



392 DISEASES OF CHILDREN. 

is the form in which there are small areas scattered over different 
parts of the lung. They do not coalesce, and varying physical signs 
are found in the several patches. The asthenic form is frequent in 
marasmic or rachitic infants, and it generally accompanies a gastro- 
intestinal infection. There is little or no fever in this type, and the 
course is protracted and often ends in death. 

Bronchopneumonia Complicating the Infectious Diseases. — With 
Pertussis. — To the symptoms of bronchitis present are added the 
objective signs of a pneumonia usually of the disseminated type. 
The temperature rises abruptly and often to 105° F. The dyspnea 
is marked and cyanosis appears early. The complication seriously 
affects the prognosis. Tuberculosis may follow in its wake if the 
child recovers. The course is usually long and tedious, remissions 
being very common. During the course of the pneumonia the spas- 
modic or paroxysmal character of the cough is not so marked as in 
uncomplicated pertussis. 

With Measles. — If, after the eruption of measles when the fever 
has subsided, there is an abrupt rise of temperature and on physical 
examination there are found crepitant and subcrepitant rales over 
localized areas, bronchopneumonia may be diagnosticated. The cough 
is increased; it is more frequent and dyspnea is more marked. The 
pulse and respirations are increased. The somnolent and apathetic 
state is again present. 

With Diphtheria. — The pneumonia is more apt to occur in 
cases having laryngeal involvement, especially those which have neces- 
sitated operative interference. It is one of the commonest causes of 
death after intubation. Bronchiectasis or pulmonary abscess may 
develop in the more chronic forms. 

With Other Exhausting Diseases. — As a terminal infection, 
bronchopneumonia may occur in a variety of diseases common to child- 
hood, more especially those that are of bacterial origin, such as typhoid 
and gastroenteritis. Where a general sepsis is present, it is sometimes 
only discovered at necropsy. 

Complications. — As has been stated above, the disease is in it- 
self mainly secondary to some other process. During its course there 
may develop an involvement of the ear, heart, peritoneum, pleura, or 
meninges. Following cases of delayed resolution, brochiectatic 
cavities, abscesses, and fibroid changes may develop. 

Differential Diagnosis. — From acute bronchitis it may be dis- 
tinguished by the milder symptoms, the lower grade of temperature 
and pulse, and the less disturbed pulse-respiration ratio. No localized 
area of bronchial breathing, bronchophony, or fine crepitant rales 



DISEASES OF THE LUXGS AXD PLEURA. 393 

will be found. Instead there will only be present numerous coarse 
and fine bronchial rales. 

From Lobar Pxeumonia. — If occurring in an infant, and there 
is a history of a primary infectious disease, bronchopneumonia is 
rather to be suspected. In the lobar type the temperature is more 
constantly high and drops by crisis, while the course is invariably 
shorter. The physical signs may not be distinctive until consolida- 
tion has taken place. Leukocytosis is higher and persists until the 
temperature falls at crisis. 

From Tuberculosis. — A bronchopenumonia of long duration 
is often regarded as a tuberculous process. It is to be differentiated 
by the tuberculous aspect of the child, the greater wasting and possibly 
by the signs of tuberculosis elsewhere. The various tests described on 
page 54 should be made as an aid to the diagnosis. 

Course and Prognosis. — The course varies from two to six weeks, 
as a rule, and only rarel}^ ends by crisis, lysis being the rule. A 
pneumonia superimposed on gastroenteritis or other debilitating 
diseases is apt to be prolonged and to leave the child in an extremely 
emaciated and asthenic condition. This is always a very serious 
disease. The prognosis is always unfavorably influenced when it 
complicates poorly nourished infants w4th infectious or constitutional 
diseases. The younger the child the more unfavorable the prognosis. 
Artificially fed infants in institutions and those with rickets or w^hoop- 
ing cough must be regarded as especially unfavorable. The signs upon 
which the practitioner may base a favorable prognosis are undisturbed 
heart sounds, absence of marked dyspnea, willingness to take nourish- 
ment, and undisturbed gastrointestinal tract. On the contrary, if 
vomiting and diarrhea, irregular breathing, meteorism, and cerebral 
symptoms develop, the outlook points to a fatal issue. 

Treatment. — The high mortalitj^ of this disease will be reduced if 
the disease is treated rationally. The vital resistance of the infant 
must be supported or increased so that the self-limited disease may 
terminate favorably. Fresh air, proper diet, hj^lrotherapy, and 
stimulation, when appropriately used, will conserve the resisting 
powers. 

Aerotherapy. — The patient should be j^laced in its crib in a large 
sunny room, the widows of which are opened to admit an abundance 
of fresh air. Light and warm clothing should be worn in the colder 
months, hot-w^ater bags or an electric thermophor being placed at 
the child's feet if the extremities are cold. A screen may be used to 
shield the patient from a direct draught. 

The diet should be a modification of the previous feedings. With 



394 DISEASES OF CHILDREN. 

the breast fed, reduce the intervals and give water before nursing. 
The food of the artificially fed should be reduced with gruel. Older 
children are allowed milk, gruels, broths, albumin water, and 
orangeade. 

The temperature should be controlled by hydrotherapeutic 
measures if it is causing unrest, insomnia, or cerebral symptoms. A 
temperature of 104° F. in one infant may cause less distress than a tem- 
perature of 101° F. in another child. A daily cleansing bed-bath should 
be given in all cases. The milder measures for the reduction of 
temperature should be first attempted — for example, an alcohol 
sponge-bath (one part to four) will usually reduce the temperature a 
degree or two, and also has a tonic effect upon the patient. The 
water may be luke-warm, but its alcoholic strength may be increased 
if the desired effect is not obtained. The naked infant is wrapped 
in a flannel blanket and one portion of the body after another is 
sponged, and by gentle friction the liquid made to evaporate, and 
thus the cooling effect is obtained. Such a bath should take from ten 
to twenty minutes and is often followed by relaxation and a refreshing 
sleep. Compresses wrung out of water at 90° F. may be placed about 
the chest and renewed hourly almost without disturbing the patient. 
The cold pack will be required in sthenic cases with high temperature 
and delirium. Ice-bags to the head, while effective in reducing tem- 
perature, are dangerous unless cautiously employed under the direct 
supervision of a competent nurse. Weak, badly nourished infants 
or those with a subnormal temperature are preferably given a hot 
mustard bath with the water at 105° F. A cheese-cloth bag containing 
an ounce of mustard is drawn through the water and the infant is 
removed when the skin reddens from the counterirritant. 

Local Applications. — Mustard pastes are especially effective in 
the beginning of the disease and should be applied directly over the 
affected area in the strength of one part mustard to six or seven of 
flour. Directions should be given as to the size and frequency of the 
application. When the skin is well reddened the application should 
be removed. If the area becomes blanched within four hours a 
second application may be made. Warm poultices and oiled silk 
jackets are only mentioned to be deprecated. 

Medication. — No drug, however harmless, should be prescribed 
without a distinct indication. The symptoms will in greater part be 
relieved by sponging and local applications. If the bowels are con- 
stipated an initial calomel purge in divided doses or an enema may 
be given. Sedatives for the cough as a routine measure, especially in 
the form of syrups tend only to produce fermentation and retard 



DISEASES OF THE LUXGS AND PLEURA. 395 

progress. A stimulating expectorant in the form of the ammonia 
preparations, as the aromatic spirits or the Liq. ammonise anisati, 
will promote freer secretion if required and also tend to support the 
heart. A harassing purposeless cough which prevents sleep can be 
profitably controlled with small doses of Dover's powder (h gr. to one- 
year-old child, q. 4 h.). 

Judicious stimulation of the heart is one of the most essential 
parts of the treatment. The physician must be guided by the action 
of the heart when the child is quietly sleeping. A rapid feeble pulse 
rate, weakness of the heart sounds, and signs of failing compensation 
are indications for drug assistance. 

Strychnin well meets many of these indications, unless the nervous 
symptoms are a prominent feature. One three-hundredth of a grain 
may be alternated wdth another suitable cardiac stimulant every four 
hours for a year-old infant. The tincture of strophanthus in drop doses 
every three to four hours is an effective remedy having no ill effects 
on the digestive tract. Alcohol in the form of brandy, if used at all, 
should be given well diluted, but never continued for any length of 
time, as nausea or vomiting almost invariably results. If the right 
heart needs assistance, nitroglycerin preferably given in the form 
of the spirits of glonoin (gr. ^^-q- to a year-old child) meets this in- 
dication. It must be frequently given, usually every two hours. 
Camphor (grs. 1 to 10 minims of sterile olive oil) should be used hypo- 
dermatically in desperate cases. If the stomach does not retain food 
or medication, the needle must be used if stimulation is imperative. 

Hypostatic Pneumonia. 

This form of pneumonia is found as a secondary affection in 
many poorly nourished children, and especially in those who are 
brought to children's hospitals for treatment. It is no doubt a result 
of lowered vital resistance. The postmortem examination shows an 
area of dark solid or semisolid lung tissue along the posterior borders 
of the lung; on cut section it is dark, grumous, and edematous. A 
serosanguinolent fluid exudes on pressure. The symptoms are those 
of a low-grade pneumonia. 

Treatment. — Combat the accompanying asthenia with stimulants, 
such as strychnia and nitroglycerin, and treat the original condition. 
All such children need particularly to be removed for a few hours 
from the sick-room and their position in the crib is to be frequently 
changed. They often breathe better if the chest is elevated on a 
pillow. 



396 DISEASES OF CHILDREN. 

Lobar Pneumonia. 

(Croupous Pneumonia.) 

A pneumonia affecting a lobe or a considerable part of a lobe 
and is caused by the diplococcus of Frankel. 

Etiology. — This form is more commonly seen in children of two or 
more years of age and is rarely secondary, as is bronchopneumonia. 

Pathology. — The apices are in our experience more frequently 
first affected in children, and then the bases. The disease passes 
through the four stages just as it does in adults; ^. e., congestion, 
red and gray hepatization, and resolution. 

Symptomatology. — The onset is sudden, most frequently with a 
chill or chilly feelings or convulsions, followed rapidly by high fever 
and rapid breathing. In some cases the nervous symptoms mask 
the pulmonary condition, simulating meningitis. The temperature 
rises to 103° or 105° F., and remissions are only slight and usually take 
place in the morning. In severe cases the prostration is complete, 
with delirium and semicoma. The child refuses food, is thirsty, 
and may complain of pain on coughing, or of abdominal pain. The 
cough may be slight or even absent for a few days, but toward the end 
is quite marked. In older children rusty sputum is sometimes ob- 
served. The disease ends by a crisis, but this is not always sharply 
defined. It may end also by lysis, especially in those children who 
have previously been enfeebled. 

Physical Signs. — Inspection. Flushed face, dilating alse nasi, and 
rapid respirations. 

Auscultation.— Bronchial breathing is noted in the early stages and 
later fine subcrepitant rales; when resolution takes place, broncho- 
vesicular breathing and many moist rales may also be present. 

Percussion. — DuUness over the affected area diminishing as the 
disease progresses and resolution takes place. 

Palpation. — Increased fremitus. 

Complications. — More or less pleurisy of a dry character is present" 
in nearly every case. Meningitis is often secondary in tJie grave or 
fatal cases. Otitis is not rare, while pericarditis and peritonitis are 
sometimes seen. Empyema should always be considered. 

Diagnosis. — The sudden onset, more constant high fever and phy- 
sical signs of consolidation differentiate it from a bronchopneumonia. 
A centralized pneumonia is often puzzling and causes a suspicion of 
typhoid fever or malaria. A blood examination will then assist the 
diagnosis. In the central pneumonia the process is enclosed in 
healtljy lung tissue, and the physical signs may not appear for several 



DISEASES OF THE LUNGS AND PLEURA. 397 

days, but the rational signs plus the fairly characteristic symptoms 
will fix the diagnosis. The pain referred to the abdomen has led to a 
mistaken diagnosis of appendicitis. Examine the lungs. 

Prognosis. — The prognosis is very good. Ninety-six per cent, of 
all cases recover. 

Treatment. — This has already been spoken of under Broncho- 
pneumonia. It is essentially the same, but may be more vigorously 
pursued, as the cases are generally of a more sthenic type. Com- 
plications by extension into the ear must be guarded against. Re- 
peated examinations of the ear-drums may be necessary. 

Pleurisy. 

Dry Pleurisy. — This is an inflammation of a localized area of 
the pleural surface, usually in conjunction with a pneumonic process, 
over infarcts or extension from a tuberculous pneumonia. These 
lesions are seen frequently postmortem; the pleural surface is found 
to be dull and lusterless with the adhesions firm or fibrinous. 

Symptomatology. — To these adhesions the pain accompanying a 
pneumonic process may be ascribed (a pleuritic friction rub is heard 
on auscultation over the consolidated area). 

The pain is sharp and lancinating, and usually produced or noticed 
after coughing. In older children it is evidenced at the end of a deep 
inspiration. 

Treatment. — Outlined under Serous Pleurisy. 

Serofibrinous Pleurisy. 

This form also results from extension of infection from a tubercu- 
lous or pneumonic process. The fluid is usually found to be sterile 
on ordinary culture media, but in cases in which perfected methods 
have been employed the tubercle bacilli may be found. 

Infants rarely have this form of plurisy; it is more commonly 
found after two years of age. The weight of opinion inclines to the 
belief that previously infected bronchial lymph-glands are the source 
of infection. 

Pathology. — On the surface of the pleura is found a fibrinoplastic 
exudate, sometimes thick, but usually thin and soft. The fluid 
which exudates is yellow or yellowish-green in color. The lung may 
be found collapsed in whole or in part. Sacculated effusions of serous 
fluid are not as common as the purulent. The bases of the lung form 
the common site; occasionally both bases are affected simultaneously. 



398 DISEASES OF CHILDREN. 

Symptomatology. — For several days there is fever, cough, chilli- 
ness and more or less pain referred to the chest. Gradually the child 
is seen to play less, is listless and apathetic. The temperature is irreg- 
ular, fluctuating from 101° to 102° F. Difficult breathing is now ap- 
parent. The pain, it should be recollected, may be referred to the 
abdomen. . Headache, constipation, and coated tongue are usual 
manifestations. The respirations and pulse are accelerated, but the 
ratio is not seriously disturbed unless the effusion is large. In the 
latter event pain is usually diminished or absent. Loss of flesh is now 
apparent, dyspnea is marked, and the child prefers to lie on the affected 
side. 

Physical Signs. — Inspection. Movement may be impaired if the 
effusion is large. The cyrtometer may show greater measurement on 
the affected side. 

Palpation. — Vocal fremitus is diminished in large collections. 

Auscultation. — The respiratory murmur is diminished and bron- 
chial breathing, distant in character, may be heard, and over the base 
all breath sounds may be absent. The breath sounds, if heard at all, 
diminish from the spine toward the axilla. Friction rales may be 
heard at or above the fluid in older children. The vocal resonance is 
diminished over the fluid itself, but does not assume the character- 
istics observed in adults. 

Percussion. — A dull or dull to flat note is elicited by percussion 
together with a sense of resistance to the percussing finger. Above 
the fluid a tympanitic note may be heard. 

Large effusions may displace the heart, liver and spleen especially 
in older subjects. Aspiration confirms the diagnosis. (See article on 
Empyema, p. 399.) 

Prognosis. — The fluid has a tendency to spontaneous absorption, 
provided purulent changes do not take place, and death rarely results 
from the effusion itself. The prognosis is unfavorably influenced if the 
fluid is due to a tuberculous focus. 

Treatment. — Rest in bed is imperative. If the fluid is small in 
amount, free bowel action, plus the use of diuretics as the Liq. ammonii 
acetatis with a moderately dry light diet may suffice for a cure. In 
large effusions, aspirate at once, then follow the plan outlined above. 
The Liq. ferri et ammonii acetatis serves very well as an after-treatment 
combined with a life in the sunlight and fresh air. Aspiration should 
be performed according to the directions given under Empyema on page 
399. If the effusion is copious a Potain aspirator or the siphonage 
method advocated by Huber will be found advantageous. 



DISEASES OF THE LUNGS AND PLEURA. 399 

Empyema. 

Empyema is known to be much more frequent, both relatively 
and absolutely, in infancy and childhood than in adult life. Statistics 
show us that 40 per cent, of pleurisies in infancy and childhood are 
purulent, while only 5 per cent, result in a suppurative pleuritis in 
adults. Yet in spite of this fact it has been mainly studied patholog- 
ically and clinically from adult life. 

The great majority of cases of empyema follow pneumonia in 
children, either the form known as pleuropneumonia or broncho- 
pneumonia. Although the infectious diseases and pyemia may be 
complicated by it, some inflammatory process in the lung or pleura 
has generally preceded the suppurative process. 

The pneumococcus we find present in the greater number of cases 
in almost pure culture. The staphylococcus and streptococcus occur 
in cases from which thin pus with little fibrin is withdrawn. We are 
as yet uncertain as to the number of cases due to the tubercle bacillus; 
as this organism is difficult to find in the. exudate, and is often reported 
as absent when the subsequent course would clinically stamp the 
case as of the tuberculous variety. Bovaird believes that six per 
cent, of all cases are tuberculous. 

The pus found in the average case of empj^ema is quite thick, 
creamy and odorless, with masses of fibrin of varying consistency 
floating in it. The fluid exudes quite slowly at first, and there is in the 
beginning an attempt made by nature to wall off this fluid by fine 
adhesions, with the result that small pockets or sacculations are 
formed; as the fluid accumulates in greater quantity, these septa are 
broken down and merged, and thus the fluid may fill the entire pleural 
cavity. 

Sacculation is frequent in children and it is important to be able 
to recognize the condition at this stage, and treat the case early before 
much damage has been done. The fluid in cases of pleurisy with 
effusion slowly becomes slightly turbid, then seropurulent, and finally 
assumes pure pus characteristics; this change being accompanied by 
a corresponding increase in the number of bacteria present. 

A study of the charts of the empyema cases at the Post-Graduate 
Hospital in New York shows that the empyema develops about the 
fourth week after pneumonia, and that the average amount of pus is 
small (5 to 8 oz.). The most frequent complications were peritonitis, 
meningitis, pericarditis, and sepsis. 

Symptomatology. — If, in a case which has recovered from a pneu- 
monic process or from an infectious disease, there is not a steady im^ 



400 DISEASES OF CHILDREN. 

provement in physical well-being, but instead a low-grade temperature, 
with increased number of respirations, accompanied by a slight hacking 
cough, pallor, sweating of the head, steady emaciation, and a marked 
leukocytosis, our suspicions should be directed to fluid in the chest. 

In spite of these warning rational signs there is probably no other 
equally great pathological change anywhere in the body so often un- 
suspected or overlooked. 

The physical signs of fluid in the chest of infants and children 
differ grossly from those of the adult. In the examination the pos- 
sibility of encapsulated or sacculated effusions must be kept in mind 
which, as has been pointed out, may contain but little pus and still 
give marked subjective symptoms. In infants the chest may contain 
fluid and we may still obtain normal or practically normal breath 
and voice sounds. 

Confirmatory physical signs above the fluid, at the level of, and 
over the fluid cannot always be obtained in young patients. Ellis' 
curve and obliteration of Traubes' space cannot be depended upon 
for assistance. Skoda's resonance may or may not be present. 

The main signs upon which reliance must be placed are marked 
dullness or flatness on percussion over any area usually resonant, bron- 
chial breathing, and marked resistance to the percussing finger, as 
distinguished from a corresponding point on the opposite side. These 
physical signs coupled with the rational signs above enumerated should 
be sufficient justification for the introduction of the needle. An 
early diagnosis is of the utmost importance, and no diagnosis of 
empyema should be regarded as complete without exploratory punc- 
ture. If in addition to these physical signs we can elicit bronchial 
breathing over the area of flatness; relative immobility of the affected 
area and bulging, with displacement of the apex beat — then omission 
to puncture would be unjust to the patient. 

Exploratory Puncture. — The exploring syringe and needle should 
be of good caliber and length, as the pus may be thick and contain 
clots of fibrin. After proper sterilization of the syringe it should be 
tested to ascertain if it is still in good working order. The skin hav- 
ing been thoroughly cleansed over the affected area, the needle can 
be inserted somewhat above the lowest point of flatness. If the 
whole side is involved we can select the most favorable points; viz., 
in the sixth interspace in the posterior axillary line on the left side 
and the fifth interspace on the right side. If we keep in mind that 
the diaphragm rises higher in children than in adults and that the 
liver must be avoided on the right side we have a fair field for 
exploration. 



DISEASES OF THE LUXGS AXD PLEURA. 



401 




With the child held in the upright position, and its arm extended 
above its head, we can thrust the needle directly forward- — noting at 
the same time the amount of force necessary to penetrate the pleura 
and partly withdraw the plunger. If no fluid appears point the 
needle upward, and then if necessary downward, and you wdll have 
explored the suspected area thoroughly and avoided the possibility 
of escaping encapsulated pus or penetrating a thick fibrinous mass. 
This method, if a strong needle is used, presents no dangers, and saves 
the child from repeated explorations, when we feel morally certain 
that fluid is present but fail to get it with the 
syringe. 

If possible, examine the exudate for bacteria, 
as the bacteriological findings, coupled with the 
duration of compression, the amount of pleural 
thickening and ability of the patient to resist the 
effect, vdll determine the prognosis. 

AVhen a clear, straws-colored fluid is with- 
drawn we can afford to wait and watch for signs 
of recession of the fluid. If this does not occur, or 
the temperature curve later shows septic character- 
istics, puncture again, and the fluid will now proba- 
bly show purulent changes. When the first ex- 
ploration shows a seropurulent or purulent dis- 
charge operative interference should not be delayed. 
Treatment. — Bouveret in his classical treatise in 1888, of nine 
hundred pages on Empyema, still advocated aspiration as the treat- 
ment in children. From two to thirt}^ aspirations were made (in one 
case 122), which indeed led to cures, but the mortality was high. 
This form of treatment is now rarely resorted to and we believe it 
finds few advocates. We would not treat an acute abscess by aspira- 
tion, and what is an empyema but a pleural abscess? Aspiration, 
then, should be employed for temporary relief of dyspneic symptoms 
only. Incision and drainage aseptically performed under light 
general or local anesthesia gives better results, and this method is 
sometimes used. The operation of rib resection is preferable in all 
cases of empyema except in very j'oung infants whose physical con- 
dition warrants any operative interference. The general subperiosteal 
operation of the eighth or ninth rib in the postaxillary line is no more 
dangerous than incision and can be as quickly performed, especially 
when we recollect that in the former operation we are often obliged 
to pass the finger through the incision to free the fibrinous masses. 
By resection we secure ample drainage space, are not hindered with 

26 



-Aspi- 



FiG. 106. 

rating syringe suita- 
ble for thoracentesis 



402 



DISEASES OF CHILDREN. 



clogged tubes, and what is most important we hasten the time of 
recovery of the patient. No permanent deformity results, as it is 
necessary to remove only one inch of the rib and the periosteum is 
preserved. The mortality is reduced also to one in seven. Instead 
of the double drainage-tube the writer uses the spool tube (see 
Fig. 107) of suitable size for the patient. This has the advantage of 
being least irritating to the pleural surfaces, and in action simulating 
a valve, allows the lung to expand with coughing efforts, and further- 
more can be easily cleansed without painful removal. This tube 
should be removed as soon as the dis- 
charge becomes serous. The sinus will 
then still be fresh and tend to close, leav- 
ing surprisingly little deformity. Irriga- 
tion except in extremely fetid neglected 
cases is not to be employed. 

The dressings are pads of sterile gauze 
(not iodoform gauze), applied over the 
opening in the tube and held to the chest 
by a Bender's elastic bandage (in which 
each thread is a twisted one). This allows 
freedom of chest movements of the unaffected side and greater degree 
of cough impulse, thus favoring the expansion of the compressed 
lung. The child should be allowed to get up as soon as possible, and 
early encouraged to blow through some musical instrument, or to 
make soap bubbles. This plan, coupled with proper tonic, dietetic, 
and hygienic treatment should give good results. 

In long standing or neglected cases of empyema in which there 
are many and firm adhesions with or without collapse of the lung, 
Lloyd advocates digitally breaking up all the adhesions and allowing 
the lung on the opposite side to inflate the collapsed lung after the 
anesthetic has been temporarily stopped. 




Fig. 107. — Spool made of soft 
rubber for drainage. 



Pneumothorax. 



Pneumothorax or air in the thoracic cavity is an exceedingly rare 
condition in early life. It is usually tuberculous, but may also 
result from traumatism, foreign bodies in the bronchi, rupture of a 
bronchiectatic cavity, pulmonary abscess, empyema, or caseating 
lymph nodes. Cases have also been reported following pertussis, 
diphtheritic and laryngeal stenosis. 

Symptomatology. — The symptoms begin very abruptly; dyspnea, 
cyanosis, thoracic pain, and a rapid thready pulse being the cardinal 



DISEASES OF THE LUNGS AND PLEURA. 403 

symptoms. Percussion elicits a tympanitic or hyperresonant note, 
as a rule, but a dull note is occasionally obtained if the pleura is 
disturbed. Vocal fremitus is absent. Voice sounds are distant, and 
metallic succussion may be obtained over the tympanitic area. 

If both air and fluid are present, the viscera may be displaced 
from their normal relations. We have observed sacculated pneu- 
mothorax resulting from a pyothorax in which the onset was gradual 
and the symptoms proportionately less intense. 

Prognosis. — This is, as a rule, unfavorable, owing to the severity 
of the underlying causes. 

Treatment. — Absolute rest to body in the prone or semirecumbent 
position must be insisted upon. Stimulation and chest strapping are 
indicated. The recent experiments with positive pressure and the 
Sauerbruch box for intrathoracic operations offer some hope for 
surgical procedure in these cases. 

Pulmonary Abscess. 

This is a rare condition resulting from the invasion of pyogenic 
bacteria, following aspirated foreign bodies in the lung, pneumonia, 
pulmonary emboh, or caseating lymph nodes. 

Symptomatology. — The symptoms develop slowly, following 
what appears to be a protracted convalescence. Often they are not 
distinctive in character. The emaciation is progressive, the tempera- 
ture, if followed closely, shows a septic curve. Profuse sour sweating 
is the rule. If combined with the above description we have thick 
purulent sputum containing leukocytes and elastic fibers, and if on 
blood examination, a marked leukocytosis (50,000 to 60,000 per cm.) is 
found, abscess of the lung should be considered and a diagnosis made 
b}^ excluding tuberculosis, encapsulated empyema and gangrene of the 
lung. In selected cases surgical treatment may be of avail. 

Gangrene of the Lung. 

Pulmonary gangrene is a rare condition in children, resulting from 
pyogenic bacteria infecting a necrotic portion of the lung. It is 
a secondary condition following pneumonia, the infectious diseases, 
bronchiectasis, the aspiration of foreign bodies, gangrenous stomati- 
tis, or necrosis of the petrous portion of the temporal bone. The 
diagnosis is more often made at necropsy than during life. 

Diagnosis. — This is founded upon the putrid expectoration of a 
dirty greenish color, which on examination is found to contain shreds 
of pulmonary tissue. The child's breath is almost always offensive. 



404 



DISEASES OF CHILDREN. 



There is progressive emaciation, prostration and an irregular tem- 
perature. The cough is somewhat paroxysmal, followed by the expec- 
toration of a good quantity of the characteristic sputum. Even 
young children will expectorate who are suffering with pulmonary 
gangrene. Following the evacuation of the pus we may be able to 
obtain the cavernous signs indicating a cavity. Hemoptysis sometimes 
follows after a severe attack of coughing. 

Course and Prognosis. — The prognosis is invariably grave. 
Careful supervision and aerotherapy may so far improve the patient's 
general condition that surgical meas- 
ures may be justifiably attempted 
with the chance of a permanent cure. 

Treatment. — Until operative 
measures can be instituted, forced 
feeding, stimulation and cod-liver oil 
should be used. Inhalations of the 
compound tincture of benzoin, tur- 
pentine, or the oil of eucalyptus will 
mitigate the foul odor. 

Bronchiectasis. 

This disease results from a 
weakening of the bronchial wall 
following a number of pulmonary 
conditions, the most important of 
which are interstitial pneumonia, 
chronic bronchitis, emphysema, 
pulmonary collapse, tuberculosis, 
and foreign bodies. The dilatations 
are cylindrical or sacculated or small 
and diffuse, and always contain a 
large number of bacteria. 

Symptomatology. — Added to the 
symptoms of the underlying disease, 
or during convalescence therefrom, 
the patient begins to expectorate 

a quantity of mucopurulent sputum. This cough is paroxysmal, 
and may be induced by changing the position of the patient from 
the diseased to the normal side. The collected sputum has a dis- 
agreeable odor, is thin, grayish-brown, and separates into a frothy, 
a watery, and a granular layer. The fever is moderate, as a rule, 




Fig. 108. — Shaded area over a bron- 
chiectatic cavity. 



DISEASES OF THE LUXGS AXD PLEURA. 405 

although exacerbations in which may occur high fever, night-sweats^ 
diarrhea and pulmonary hemorrhage, are not uncommon. 

Physical Signs. — In a typical case, with a well-developed cavity, 
cavernous or amphoric breathing with diminished vocal resonance 
may be heard over the affected area. After a free expectoration, nu- 
merous coarse mucous rales with bronchophony may be obtained. On 
percussion a tympanitic note is heard. Other evidences may be 
found in the clubbed fingers, emphysematous areas, or the develop- 
ment of a j^ulmonary gangrene. 

Diagnosis. — The paroxysmal coughing occurring on change c^ 
position, with large quantities of expectoration, with the general con 
dition not proportionately affected, tend to differentiate it from the 
more acute condition of pulmonary gangrene which causes marked 
prostration and shows in the sputum portions of lung parenchyma. 
The needle may distinguish it from abscess, and the sputum examina- 
tion from pulmonary tuberculosis. 

Course and Prognosis. — The disease may extend over many 
months or years, but complete recovery is extremely rare. Complica- 
tions are easily acquired leading to a fatal result. 

Treatment. — This should be directed toward conserving the 
strength of the patient by the use of nourishing food and a protracted 
sojourn and life in the mountains or at the sea-shore. The inhalation 
of the volatile balsams, such as benzoin, turpentine, or eucalyptus, 
are indicated. 

Quincke's postural method, raising the foot of the bed; or the 
method of expiratory compression may be used if the cavity does not 
thoroughly empty itself after coughing. Terpene hydrate or guaiacol 
carbonate may be administered internally. Resection of the ribs,, 
collapse, and drainage of the cavity has been attempted, but thus far 
wuth indifferent results. . 

Foreign Bodies in the Respiratory Tract. 

Various objects may find their way into the larynx, trachea, or 
even into the bronchi by accidental inspiration at the time of coughing 
or laughing when the foreign body is in the mouth. Among the 
objects we have collected are an upholsterer's tack, the glass eye of a 
doll, fish bones, and a carrib bean. 

Symptomatology. — A sudden violent fit of coughing or choking 
follows the aspiration and cyanosis results; extraordinary efforts 
are made by the child to breathe. Occasionally the paroxysm is so 
slight as to be mistaken for whooping cough or croup. If the object 



406 DISEASES OF CHILDREN. 

is sharp, as a fish bone for example, there is some local irritation or 
later symptoms of obstruction. The attacks may be followed by 
periods of comparative quiet and rest. If the object is small and 
smooth and is not coughed up at once, it will eventually find its way 
into a bronchus. It passes usually, owing to its position, into the 
right bronchus. 

Diagnosis. — If a history is obtained and the symptoms of the 
initial suffocative attack are well described, the diagnosis maybe made, 
without the knowledge that an object has been aspirated. When the 
symptoms come on gradually, the diagnosis may be entirely obscured. 
However, a bronchiectatic cavity, pulmonary collapse, or abscesses 
should lead to a careful investigation with this diagnosis in mind. 
An X-ray examination may materially aid in clearing up a suspected 
case. 

Treatment. — The finger or the laryngeal forceps may succeed in 
removing a recently aspirated object. If unsuccessful, tracheotomy 
may be necessary in cases which would otherwise suffocate, surgical 
measures for the removal of the foreign body being later employed. 

Direct laryngobronchioscop}^ with Killian's instrument has 
rendered excellent service in the removal of objects from the bronchi. 

Subphrenic Abscess. 

This consists of an accumulation of pus between the liver and 
the diaphragm on the right side, or between the stomach, spleen, and 
diaphragm on the left side. Downward extension of an empyema 
through the diaphragm is the usual cause in children, although it 
may result from intraabdominal disease. It may also complicate 
conditions such as appendicitis and acute pneumonia of the septic 
type. Empyema is most often diagnosticated and the real condition 
discovered at operation. Rarely the abscess contains air, and 
pyopneumothorax may be suspected. 

Symptomatology. — Beside the symptoms of the primary con- 
dition there may be added chills, rapid pulse, remittent fever, localized 
pain and tenderness, nausea and vomiting with impeded respirations. 
In a case seen by one of us there was a moderate amount of bulging, 
and the liver was raised upward by the pus. 

Treatment. — Prompt surgical intervention with the establish- 
ment of drainage is imperative. The prognosis should be guarded. 



SECTION A7II. 
DISEASES OF THE CIRCULATORY SYSTEM. 



CHAPTER XXVII. 
DISEASES OF THE HEART. 

Two factors in early life contribute to the Adgor of the circulation: 
(1) The strength of the heart muscle itself and the readiness with 
which it hypertrophies when compensation is required. (2) The 
elasticity of the arteries. It is frequently not appreciated how im- 
portant a function the arteries play in the round of the circulation. 
By their tonicity they aid the heart in propelling the blood in a con- 
stant stream to the various parts of the body. If the arteries are 
healthy and elastic great help is thus afforded the heart in the equable 
distribution. of the blood. Even a crippled heart acts to much better 
advantage when the arteries can perform their full share in the work 
of the circulation. Thus in early life when the arteries are nearly 
always in a sound condition^ a lesion of the heart may produce com- 
paratively little discomfort, especially when compensatory hyper- 
trophy is satisfactory, as is very apt to be the case. When, however, 
middle age approaches and a stiffening of the arteries ensues from 
atheromatous change, we will soon encounter dyspnea and other 
evidences of a failing circulation. 

The blood pressure itself, as registered by the sphygmomanometer, 
is lower in children than in adults. The normal limits of systolic 
pressure at different ages have been given as follows: 

Infants, 75 to 90 mm. 

Children, 90 to 110 mm. 

Young adults, 100 to 130 mm. 

Older adults, 110 to 145 mm. 

In a series of observations made by us at the Postgraduate 
Hospital with the Stanton sphygmomanometer, the above figures 
were confirmed, and observations were made in diseased conditions; 
but while of interest, it was not found that this instrument was of 
much practical value in early life. 

The Heart. 

The infant has relatively a larger heart than older children and 
adults, and it assumes a more horizontal position from a greater 

407 



408 DISEASES OF CHILDREN. 

breadth. The apex beat iPx early Ufe is in the fifth intercostal space 
and is sometimes a little external to the mammary line. With in- 
creasing age the apex bea^ deflects a little downward and inward, 
reaching well within the mammary line. 

Enlargement of the heart may be noted by the position of the 
apex beat and by an increased area of dullness on light percussion. 
The space for such percussion is situated between two parallel lines, 
one line running through the middle of the sternum and the other 
through the left nipple. Absolute heart dullness will be noted in a 
small triangle formed by the left border of the sternum, the lower 
border of the fourth rib and a line running from the fourth rib just 
within the mammary line to the third costal cartilage near the left 
border of the sternum. The dullness caused by the left ventricle will 
be marked out by percussing inward from the mammary line over 
the second, third, fourth,, and fifth ribs; that caused by the right 
ventricle will be located by percussing over the fourth interspace 
beginning outside the right sternal line and percussing toward the 
sternum. Dullness caused by the apex may be noted by percussing 
from the middle of the sternum along the fifth interspace to the ante- 
rior axillary line. 

The heart beats with great rapidity in early life and it is often 
puzzling to determine accurately the character of the sounds heard. 
The pulmonic second sound is accentuated throughout the early 
years and a certain arythmia is often observed. The pulse is fre- 
quently irregular and its rapidity is greatly influenced by any dis- 
turbing conditions, such as crying; it also varies much during waking 
and sleeping hours. The following may be considered as a fair general 
average ; 



Newborn, 


120 to 140. 


First year, 


110 


Second year, 


100 


Fifth to eighth year. 


90 



Congenital Heart Disease. 

{Cyanosis; Blue Disease.) 
New-born infants sometimes exhibit a persistent blueness due to 
malformation of the heart. This defect usually takes the form of 
deficiency in the interauricular and interventricular septa. The great 
vessels may likewise be involved in the malformation, especially the 
pulmonary artery. Dr. J. L. Smith found in over half of the 162 
cases he examined at autopsy that the pulmonary artery was absent, 



DISEASES OF THE HEART. 



409 



rudimentary, impervious, or partiallj^ obstructed. He also found the 
following lesions: Right auriculoventricular orifice impervious or con- 
tracted; orifice of the pulmonary artery and the right auriculoventric- 
ular aperture impervious or contracted; right ventricle divided into 
two cavities by a supernumerary septum; one auricle and one ventricle; 
a single auriculoventricular opening, with interauricular and inter- 
ventricular septa incomplete; mitral orifice closed or contracted; 
aorta absent, rudimentary, impervious, or partialh^ obstructed; aortic 
orifice and left auriculoventricular orifice impervious or contracted; 
aorta and pulmonary artery transposed, the vena cava entering the 
left auricle; pulmonary veins opening into the right auricle or into 
the vena cava or azygos veins; aorta impervious or contracted above 
its point of union with the ductus arteriosus; the pulmonary artery 
wholly or in part supplying blood to the descending aorta through the 
ductus arteriosus. 

It is obvious that with any of these grave central lesions not only 
the peripheral circulation, but the nutrition as well must suffer. The 
blood is deficient in oxygen and has an excess of carbon dioxid. The 
blueness is most pronounced in the prominent parts of the face, such as 
the eye-brows, cheek-bones, nose, and lips. The hands and fingers 
are also prominently affected. The color varies from a light to a very 
deep purple, the discoloration being aggravated by crjdng or other dis- 
turbing influence. 

While the infants at birth may be well developed, there are soon 
evidences of failure of nutrition, and the}^ are very susceptible to inter- 
current diseases. The action of the heart is rapid and tumultuous, and 
the respiration is correspondingly disturbed. Various bruits are heard 
upon auscultation of the heart, especially a systolic murmur at the 
base. The right heart is usually enlarged. The infants suffer from 
lack of sufficient animal heat, and because of this and pulmonary con- 
gestion they easity contract pneumonia. They are apt to be carried 
off by any intercurrent disease, and whooping-cough is especially badly 
borne. In a majority of cases of congenital heart lesion, the general 
blueness is noted immediately or very shortly after birth. In a minor- 
ity of cases, however, the lividity is not noticeable for an interval of 
time, varying from a few weeks to a few months after birth. A few 
cases have been reported where even a few years have elapsed before 
the blueness has become marked. The defect occurs more frequently 
in male than in female infants. While this peculiarity has been noted 
by most observers no explanation can be given of it. Most cases do 
not survive the first year, but occasionally a case will live through 
infancy and childhood. It is very rare to find one surviving adoles- 



410 dis;eases of children. 

cence. Those that survive infancy present a stunted appearance, 
although well formed at birth. The chest becomes deformed, with 
a projecting sternum, and the fingers and toes bulbous from the slug- 
gish circulation. Anasarca may occur toward the end of life, to be 
noted in the face or ankles, and rarely in other parts of the body. 
Death may take place from exhaustion, during a paroxysm of dyspnea, 
from convulsions or from a feeble resisting power in some intercurrent 
disease. 

Diagnosis. — In order to distinguish congenital from acquired heart 
disease, it may be borne in mind that the latter is rarely seen in infancy, 
especially early infancy. The congenital type shows early and general 
blueness, marked dyspnea, defective development with bulbous fingers 
and toes. There is likewise no appearance or history of rheumatism 
or acute endocarditis. The commonest bruit is the loud murmur at 
the base. 

Treatment. — A general hygienic oversight is the most that can be 
accomplished. The infants must be kept warm and carefully fed. 
If the blueness and dyspnea become extreme, oxygen may give tem- 
porary relief. Small doses of digitalis may be occasionally given as 
an aid to the circulation. 



Acute Endocarditis. 

Endocarditis is an inflammation of the endocardium which espe- 
cially affects the lining membrane of the valves and the parts con- 
tiguous to them. 

Etiology. — The commonest cause is acute rheumatism, and, in 
some cases, it may be the first and even the only manifestation of this 
common disease. Usually, however, it is preceded by several attacks 
of the mild form of rheumatism seen in early life. It is also not in- 
frequently seen in connection with chorea. The latter disease may 
alone be responsible for endocarditis or it may be associated with 
rheumatism, the two conditions either preceding or following the 
heart attack. Roger considers that rheumatism, chorea and endo- 
carditis are frequently manifestations of the same underlying patho- 
logical condition. Any infectious disease may attack the endocardium, 
especially scarlet fever, cerebrospinal fever, diphtheria, and typhoid 
fever. In some cases influenza may act as a cause. Any of the septic 
conditions are also liable to provoke inflammation in the endocardium. 

Pathology. — In fetal life the right side of the heart is attacked, 
but this rarely occurs after birth when the left side is almost exclusively 
affected. The valves are most frequently the seat of the inflammation, 



DISEASES OF THE HEART. 411 

the mitral valve being oftenest affected and next the aortic and occa- 
sionally the pulmonary valves. The affected valve is thickened from 
a proliferation of connective-tissue cells and may be covered by small 
deposits of fibrin, especially around the margins. Small thrombi 
and vegetations may also be present, which are liable to separate and 
be carried into the general circulation. In this manner secondary 
infections are liable to take place in various vital organs. Leakage 
of the valve may be caused by contractions of the chordae tendinse cr 
ulceration with perforation of the valve. Streptococci or the staphylo- 
coccus pyogenes are the bacteria that most frequently infect and inflame 
the endocardium and rarely pneumococci, either from the presence 
of the bacteria or their toxins in the blood stream. The tonsils have 
been supposed to be the primary seat' of many of the bacteria that 
thus affect the heart, and cases have been reported of endocarditis 
following tonsillitis. There is usually some inflammation of the myo- 
cardium coexisting with endocarditis which causes a softening of 
the heart muscle and consequent dilatation. This may account 
for some of the valvular insufficiency seen during and after the attack. 

Symptomatology. — The symptoms are often very obscure, 
being masked by the original infectious disease that is the cause of the 
heart lesion. On this account the heart must be frequently and care- 
fully examined during attacks of rheumatism, scarlet fever, diphtheria, 
and in any septic condition. A soft, systolic murmur is usually heard, 
most noticeable at the apex and transmitted toward the axillary region. 
There may be slight dyspnea and evidences of some dilatation, espe- 
cially if the child cannot be kept quiet. An irregular fever with in- 
creased respiration and pulse rate may also be noted. Young children 
rarely complain of pain or discomfort in the cardiac region but 
older children may describe a feeling of constriction, slight pain, or 
palpitation. 

Septic Endocarditis. — The symptoms of this form of endocarditis, 
otherwise knoAvn as malignant or ulcerative endocarditis, are much 
more urgent and marked. There are chills with high, irregular fever 
and sweats. There is likewise great prostration, with delirium and 
even coma. There are no characteristic symptoms referable to the 
heart beside a murmur and possibly more marked dyspnea than in the 
ordinary attacks. Ulcerations take place on the valves, and septic em- 
boli are liable to be detached and carried to the lungs, kidneys, brain, 
or other vital organs. A typical sign consists of purpuric spots or 
petechia which soon appear on the neck, chest, abdomen, or extremi- 
ties. This form of endocarditis may occur in any septic condition, 
when various bacteria mav be found in the blood and thus the cause 



412 DISEASES OF CHILDREN. 

of the heart lesion demonstrated. Fortunately, septic or malignant 
endocarditis is very rare in early life and it is a fatal disease. 

Diagnosis. — A soft, systolic murmur at the apex that develops 
during an illness, with irregularity of the heart's action and some 
dilatation is suspicious of endocarditis. The murmur is transmitted 
toward the axilla and is usually accompanied by fever and increased 
rapidity of the pulse. A purring thrill may also be present and an 
increased pulsation over the area of the heart's action. Hemic or 
myocardial murmurs are inconstant, are noted especially at the base 
or over the pulmonic area and are not transmitted. These murmurs 
are usually systolic, but there is no evidnece of dilatation or marked 
cardiac disturbance and there is absence of fever and other signs of 
acute illness. Pericarditis is recognized by the friction sound, or 
dullness on percussion, or absence of distinct apex beat when effusion 
is present. 

Prognosis. — The prognosis is good as regards life, except in the 
septic or ulcerative form. The outlook is not so good with reference 
to the future crippling of the heart from thickening or retraction of the 
valves. Cases have been reported, however, in which no permanent 
lesion has followed endocarditis, especially when the disease has been 
early recognized and the child kept quiet. Most of the cases, espe- 
cially those of rheumatic origin, are followed by some permanent lesion. 

Treatment. — Rest in bed in a recumbent position is very impor- 
tant during the acute stage. Any exertion that results in dilatation 
of the softened heart muscle will cause valvular insufficiency. An 
ice-bag may be placed over the heart in cases of severe palpitation. 
Tumultuous heart action may also be controlled by aconite or by 
small, non-narcotic doses of opium. The latter drug will also tend 
to allay restlessness and thus render it easier to keep the child quiet. 
Grains -5^0" to -gV of morphin sulphate may thus do good service. If the 
heart's action is weak, with evidences of dilatation, strychnia or 
digitalis will be indicated. Where rheumatism is present, it may be 
treated by sodium salicylate, aspirin, or alkalies. The bowels must be 
kept open, and a light, fluid diet given. In cases having a weak or 
dilated heart with irregular pulse, it may be necessary to keep the child 
quiet in bed for some weeks or until a distinct improvement is noted. 

In septic endocarditis blood cultures should be made twice a 
week in the effort of finding the organism. (This requires expert and 
specialized laboratory technic.) When the organism is found a 
homologous vaccine can be made and used according to Wright's 
method. Recent reports (Thompson, etc.) have been extremely en- 
couraging in this heretofore fatal disease. 



DISEASES OF THE HEART. 413 

Myocarditis. 

Myocarditis is an inflammation of the heart muscle followed by 
softening and degeneration. 

Etiology. — The toxins produced by the bacteria of the various 
infectious diseases may cause an inflammation of the heart muscle. 
Diphtheria and scarlet fever are the diseases most often responsible 
for thus attacking the heart. 

Pathology. — In some cases there is a cloudy swelling and a granu- 
lar and hyalin degeneration of the muscle fibers, and in others there 
will be a fatty degeneration. If the latter is extensive, a cut section 
will show a yellowish appearance of the heart muscle. There may 
also be a small, round-celled infiltration between the muscular fibers. 

Symptomatology. — The milder forms of the disease may show no 
symptoms referable to the heart. In severer attacks there will be 
dyspnea, faint feelings, and a rapid, irregular pulse. It is difficult to 
locate the position of the apex beat, and there will bean increased area 
of cardiac dullness due to dilatation. The grave cases show general 
pallor with cyanosis of the lips and finger-tips, and a sudden collapse 
from heart failure may be the terminal condition. The symptoms 
are liable to be masked, as in endocarditis, by the primary infectious 
disease. Vomiting, occurring in connection with a weak, irregular 
pulse in diphtheria, is usually of serious import. A pulse becoming 
slow in an infectious disease, especiall}^ diphtheria, after having been 
rapid is of grave significance. We have seen the pulse drop from 150 
to 50 and 40, and, in one case it reached 25 in diphtheria with a com- 
plicating myocarditis. Death nearly alw^ays ensues in cases having a 
very slow pulse. In chronic and severe valvular disease, a lack of tone 
in the heart muscle due to a slow and progressive myocarditis will be 
shown by failure of compensation with resulting dyspnea, congestion 
and enlargement of the viscera, and dropsies. 

Diagnosis. — The diagnosis rests upon a weak and irregular action 
of the heart, a feeble first sound, and accentuation of the pulmonic 
second sound and diflflculty in locating the apex beat. In addi- 
tion to these local signs there will be faintness, pallor, and general 
prostration. 

Treatment. — The heart must be supported by absolute rest in the 
recumbent position. Sudden dilatation and weakness may be com- 
bated by hypodermatic injections of small doses of morphin and atro- 
pin. Sulphate of strychnin is useful in sustaining the heart's action. 
Prolonged rest and avoidance of exertion must be insisted upon during 
convalescence. 



CHAPTER XXVIII. 
CHRONIC VALVULAR DISEASE. 

Physicians are often called upon to treat cases with valvular dis- 
eases of the heart when it is impossible to find out the beginning of the 
trouble. The patient may be unable to give a history either of 
rheumatism or endocarditis, but seeks advice for dyspnea, swelling 
of the extremities, or other symptoms of failing circulation. We 
believe that a large proportion of the cases of valvular disease in the 
adult have started during childhood. The first beginning of the 
trouble, which is the period for hopeful treatment, is not recognized. 
The nature of the rheumatism that attacks children is often obscure, 
and several attacks of wandering or so-called ''growing pains" may be 
overlooked. While the heart may be the first structure attacked by 
rheumatism, this is not the common order of events. In most of 
our histories of valvular disease in children, the cardiac affection 
seemed to come on after several attacks of rheumatism. Great care 
should be exercised in making an early diagnosis, and vigorous meas- 
ures be taken to combat these first manifestations of rheumatism, 
fearful that, although the heart may escape the first mild attacks, 
it may suddenly and unexpectedly become affected by an equally 
light manifestation of the disease. 

When endocarditis ensues, as previously noted, the symptoms are 
often very obscure. Palpitation, slight pain, and breathlessness, with 
a dry cough, may not be particularly noticed by parents. In all 
suspicious cases we would strongly emphasize the importance of a 
careful examination of the heart on the part of the physician, a 
stethoscope being used. Just at this juncture rest is indicated above 
all things. If this is not procured, the delicate, softened heart muscle 
quickly undergoes dilatation, followed by permanent damage to the 
valve. Dilatation takes place very readily in the young subject. If 
it is true that endocarditis need not always nor necessarily eventuate 
in permanent valvular disease, and this seems to be generally believed, 
we may certainly aid such a result by doing all in our power to avoid 
dilatation. By recognizing the endocarditis at the beginning and 
keeping the child as quiet as possible, we may thus seek to avoid 
dilatation and consequent crippling of the valves. Even after the 

414 



CHRONIC VALVULAR DISEASE. 415 

immediate symptoms of endocarditis have passed, children are too 
often allowed to take part in all lands of vigorous exercises as if 
nothing amiss had happened. 

In many cases children suffering from chronic valvular disease 
show few symptoms of circulatory disturbance. This is explained 
by a more or less perfect compensation which generally and completely 
ensues from hypertrophy, and there may thus be no positive sign 
until years later that serious damage has been effected. The periph- 
eral arteries are also healthy and elastic at this time, which fact, as pre- 
viously noted, greatly facilitates the work of the heart. As the patients 
grow older, and vascular degenerations begin, and the limit of com- 
pensatory hypertrophy is reached, marked dyspnea and other symp- 
toms of a failing circulation will be noted. We have seen children 
after a severe, neglected case of endocarditis, or after several attacks, 
suffer in this way, but in a large number of cases the principal evidence 
of valvular disease will be shown by general underdevelopment, mal- 
nutrition, and anemia. 

The extent of the heart lesion cannot be estimated by the rela- 
tive loudness or softness of the murmur. We must estimate the 
amount of crippling caused by valvular defect by two factors in our 
examination of the lieart : first, the position of the apex beat, and second 
a marked accentuation of the pulmonic second sound. If there is no 
hypertrophy of any part of the heart muscle, it is not probable that 
any real valvular defect is present. While in early life the pulmonic 
second sound is relatively louder than in later years, if it is very 
markedly accentuated, there is evidently an interference to the pas- 
sage of the blood through the lungs due to some valvular lesion. 

In early years, the mitral valve alone is most frequently the seat 
of chronic disease; next a combination of mitral and aortic lesions is 
found, and very rarely the aortic valve alone is affected. This is ex- 
plained by the fact that the mitral valve is most often attacked by 
rheumatism, while atheroma, gout, and old age are the commonest 
causes of aortic disease. 

Location of the Valves. — The mitral valve is situated at a point 
where the upper border of the left fourth costal cartilage joins the left 
border of the sternum. The aortic valves are placed behind the ster- 
num at the junction of its left margin with the lower edge of the third 
left costal cartilage. The pulmonary valves are located at the junction 
of the left border of the sternum and the third left costal cartilage. 
The tricuspid valves are found behind the middle of the sternum on 
the level of the line connecting the fourth costosternal cartilages. 
The valves of the left heart are situated deeper than, and behind those 



416 DISEASES OF CHILDREN. 

of the right heart. Organic defects in the valves give rise to adven- 
titious sounds known as organic cardiac murmurs, produced by the 
passage of the blood over or through the valves affected. These mur- 
murs are not heard with maximum intensity directly over the valve 
affected; but near it; and are transmitted in the direction of the blood 
current. The following are the locations of the loudest sounds in the 
valves w^hen diseased: mitral murmurs loudest at the apex; aortic 
murmurs loudest at second right intercostal space: tricuspid murmurs 
loudest at the ensiform cartilage. 

Mitral Regurgitation. 

Any insufficiency or leak in the mitral valves will be followed by 
regurgitation of blood during the systole. There will then ensue, first, 
a dilatation and hypertrophy of the left auricle; next, hypertrophy of 
the left ventricle required by the extra work thrown upon it in propel- 
ling the blood through the aortic valves, and, finally, an hypertrophy 
of the right ventricle which has difficulty in forcing the blood through 
the lungs to be emptied in the left auricle. 

A physical examination will show general evidence of enlargement. 
A visible impulse of the heart's action can usually be detected and the 
apex beat is felt below and to the left, or outside its usual location. 
On percussion, the area of dullness will be increased to the left and 
below, from enlargement of the left auricle and ventricle. On auscul- 
tation a systolic murmur is heard, having a blowing and rarely a 
musical character. The murmur is transmitted from the apex across 
the axilla to the inferior angle of the left scapula. The murmur is 
sometimes heard in children at the latter location behind, plainer than 
at the apex at front. An accentuation of the pulmonic second sound 
is usually marked. 

Mitral Obstruction. 

A presystolic or auriculoventricular sound is produced by some 
interference with the normal and easy passage of blood through the 
auriculoventricular septum or valve. The murmur is rough and 
blubbering in quality, beginning at the end of diastole and ending ab- 
ruptly with systole. One of the most characteristic points about this 
murmur is its abrupt termination. This quick stop of the abnormal 
bruit is very different from the gradual ending of mitral regurgitation. 
The obstruction in the valve leads to hypertrophy of the left auricle and 
finally to enlargement of the right ventricle which has more work to do 
in flushing the blood through the lungs. The left ventricle is not 



J 



CHRONIC VALVULAR DISEASE. 417 

hypertrophied, and accordingly the apex beat will appear in about its 
normal location. Any enlargement will be noted by an increased area 
of dullness to the right of the sternum. A purring thrill is usually 
felt by placing the hand over the heart. On auscultation a blubber- 
ing murmur is heard only in the region of the apex and is not trans- 
mitted. It is likewise somewhat variable and may be hardly audible 
during repose and yet very evident when the patient is required 
to make some exertion. The pulmonic second sound is always 
accentuated. 

Chapin has reported a series of forty cases in which children 
giving evidence of mitral obstruction were kept under observationr 
for different intervals of time from a few weeks to several years. The 
commonest symptoms noted were varying degrees of pain referred to 
the region of the heart and dyspnea on exertion. Thirty-one of the 
cases gave evidence of simple mitral obstruction, while in nine cases 
there were combined murmurs. Most of the cases were preceded by 
a rheumatic manifestation that was mild even for children, and he 
concludes that while mitral stenosis is not independent of rheumatism 
it is apt to be associated with the less pronounced forms of it. 

In growing children, especially girls, who are pale, nervous, 
anemic, and troubled with digestive disturbance, an irregular action of 
the heart may produce a rough sound simulating mitral obstruction, 
which disappears under improved conditions. 

Aortic Obstruction. 

This lesion is infrequent in childhood. It is accompanied by a 
systolic murmur heard at the base at the second right interspace and 
transmitted upward. The aortic second sound is somewhat w^eakened, 
but there is no accentnation of the pulmonic second sound. There is 
hypertrophy of the left ventricle and the apex beat is accordingly 
pushed downward and outward. The latter will distinguish this sound 
from functional or hemic murmurs with which it is apt to be confused. 

Aortic Regurgitation. 

This lesion is likewise not very frequently seen in early life. 
The murmur is diastolic, taking the place of the aortic second sound. 
It is rather harsh in character and is transmitted downward over the 
sternum, being heard with greatest intensity at about the fourth 
cartilage or sometimes at the lower extremity of the sternum. There 
is great hypertrophy of the left ventricle, and accordingly much dis- 
placement of the apex beat downward and outward, and the heart 



418 DISEASES OF CHILDREN. 

usually acts with considerable force. The so-called '^water-hammer 
pulse" is typical, consisting of a full, arterial wave followed by a 
sudden fall in the pressure. 

Tricuspid Regurgitation. 

This lesion is very rare and apt to be overlooked. It may be 
caused by disease of the valve itself or secondary to a dilated right 
ventricle. There is a very soft systolic murmur heard over the 
ensiform cartilage. It is distinguished from aortic regurgitation by 
being systohc instead of diastolic, and also by more marked cyanosis, 
by pulmonary edema, and jugular pulsation. 

Prognosis in Valvular Disease. — The immediate prognosis in 
children, even when the lesion is fairly severe and extensive, is usually 
good for reasons already noted. There is nearly always, however, a 
more or less defective nutrition. There are cases in which shght 
lesions appear to undergo complete recovery, especially when a 
healthy general growth can be accomplished. Repeated attacks of 
rheumatism, with the danger of renewed endocarditis, are a grave 
menace to the heart by upsetting compensation and increasing existing 
lesions or forming others. The ultimate prognosis is not good in 
most cases of marked valvular disease, as it is only a question of time 
when the compensation will fail in later life. 

Treatment. — Many cases require no treatment directed to the 
heart, but the general nutrition and growth require careful oversight. 
Nourishing, digestible food, with the occasional administration of 
remedies to build up tissues, such as iron and cod-liver oil, are fre- 
quently all that are required. These cases should not be restricted too 
much in exercise and amusement. All the milder games may be 
allowed, only avoiding the more violent and competitive sports. Any 
acute infectious disease and the shghtest manifestation of rheumatism 
must mean extra rest, and anxious care on the part of the physician. 
Any evidence of failing compensation will likewise require rest and the 
administration of heart tonics, especially strychnin and digitalis. 
In cases of great dyspnea and restlessness small doses of codein by the 
mouth or minute non-narcotic doses of morphin given hypoder- 
matically will often afford relief. 

Functional Cardiac Disorders. 

The heart in growing children, especially those with a neurotic 
tendency, is very prone to functional disorder. Digestive disturbances 
and the anemias are the commonest exciting causes. 



CHRONIC VALVULAR DLSEASE. 419 

Palpitation of the heart. — This is seen in connection with dyspepsia 
from the use of improper food or from the abuse of tea, coffee, or con- 
diments. In older children the strain from overstudy or from mastur- 
bation, especially at the time of adolescence, is a common cause. 
The heart may be unusually slow or rapid in action, but oftener the 
latter. 

Hemic Murmurs. — These murmurs are not often heard in infants 
and very young children, but are fairly frequent in older children. 
They are invariably systohc and are usually heard at the base. A 
diastolic murmur is always organic. The hemic murmurs are heard 
more distinctly over the pulmonary than over the aortic interspace, 
are inconstant, and are not transmitted in the direction of the blood 
current. They are usually accompanied by a venous hum in the 
jugular and subclavian veins. The most reliable differentiation 
between hemic and organic murmurs consists in the enlargement of 
the heart from compensatory hypertrophy seen in the latter. Mur- 
murs, apparently of hemic origin, are sometimes noted in acute febrile 
affections. Dynamic murmurs, due to a faulty action of the heart 
muscle, are sometimes detected after violent exercise and in choreic or 
hysterical children. A cardiorespiratory murmur may be produced 
by the impulse of the heart against some of the pulmonary vesicles 
at the end of a deep inspiration. It is always systolic and is not heard 
at the end of expiration. 

Treatment. — The management of functional heart troubles is 
principally dietetic and hygienic. The digestion must be carefully 
regulated and only nourishing and easily assimilable food be allowed. 
It may be necessary to remove the children from school so that they 
can be free from nervous strain and have more opportunity to get 
plenty of fresh air and sunlight. All the known sources of nervousness 
must be removed and opportunity given for abundance of sleep. 
Iron and cod-liver oil are the best remedies. Small doses of Fowler's 
solution may also be employed. 



CHAPTEH XXIX. 
DISEASES OF THE PERICARDIUM. 

Pericarditis. 

This is an inflammation cf the pericardium secondary to rheu- 
matism or some infectious disease. 

Etiology. — The most frequent cause is acute articular rheu- 
matism. It may also occur in connection with the exanthemata, 
especially scarlet fever, in various septic processes, in tuberculosis 
and pneumonia. Direct injury is rarely a cause, and it may spread 
by continuity from pleurisy. The following bacteria may act as 
exciting causes — streptococci, staphylococci, the tubercle bacillus, 
the colon bacillus and the pneumococcus. 

Pathology. — We may recognize three varieties— the fibrinous, 
serofibrinous and purulent, according to the inflammatory exudate. 
In the first or adhesive form, the pericardium is covered by an exuda- 
tion of fibroplastic matter which may lead to adhesions between the 
visceral and parietal surfaces. In the serofibrinous form, the peri- 
cardial sac contains a serous fluid, together with a fibrinous exudation, 
which produces adhesions on absorption of the fluid. The sero- 
fibrinous exudation may occasionally become purulent, and rarely 
blood is exuded into the sac. Miliary tubercles may infiltrate both 
the visceral and parietal surfaces in the tuberculous form. Permanent 
adhesions will be produced by the fibrinous exudation being replaced 
by new connective tissue. More or less myocarditis is present in 
connection with pericarditis, the same as in endocarditis. 

Symptomatology. — The symptoms are of such a negative character 
that the disease is often overlooked. As it is usually a secondary 
condition, the original disease is apt to mask the symptoms that are 
present and occupy all the attention of the physician. Palpitation 
of the heart, dyspnea, more or less pain in the epigastric region, rapid, 
irregular pulse, and increased respirations are usually present. In 
severe cases cyanosis may be marked. Where pus is present in the 
effusion, the temperature assumes a more remittent curve. 

Physical Signs. — As the rational signs are obscure, the physical 
signs assume great importance in making a diagnosis. In the fibrous 
form, a superficial friction sound, synchronous with the beat of the 

420 



DISEASES OF THE PERICARDIUM. 421 

heart may be detected. It may be heard on systole alone, or with 
both systole and diastole. It is usually more distinct at the base, but 
it may also be heard toward the apex, especially at the onset of the 
disease, and is not transmitted. At first, the sound may have a 
crepitant quality, but later assumes a coarser, rubbing, or rasping 
character. A friction fremitus may be felt over the region in which 
the friction rub is localized by auscultation. 

In the serous form there may be some bulging at the precordial 
region, depending upon the amount of the effusion. From one to 
two fluidounces must be present in the pericardial sac in order to pro- 
duce marked signs. The apex beat is not distinct, being pushed up- 
ward and to the left. Where there is extensive effusion, the apex beat 
may be lost. There will be an increased area of precordial dullness 
over the distended sac. It may extend on the left outside the mam- 
mary line from the seventh rib up to the first rib, and from a little to 
the right of the sternum down to the liver. As in plueral effusions, 
there will be a slight resistance to the finger on percussing. On aus- 
cultation the heart sounds are muffled or feebly heard, and the apex 
is located with diffi"culty, if at all. As the fluid is absorbed the friction 
rub will again be noted and the valvular sounds become more distinct. 

Diagnosis. — This must be made by a careful examination of the 
heart in reference to the physical signs just noted. In endocarditis the 
apex can be located and the soft, blowing murmur is transmitted. 
Acute dilatation of the heart and hypertrophy will show an enlarge- 
ment and increased area of dullness, but there will be no friction 
rub nor signs of effusion, and the previous history will help to throw 
light on the case. A left pleural effusion, with or without pericardial 
effusion, may raise a difficult point in diagnosis. The flatness from 
the pleural effusion will not extend over the heart and sternum if 
there is no pericardial effusion, but, if both are present, the extensive 
dullness and feeble or absent heart sounds will afford a probable 
diagnosis. 

Prognosis. — The immediate outlook is good except in the septic 
and purulent forms of the disease. The heart may, however, be per- 
manently crippled in the case of extensive adhesions. 

Treatment. — The child must be kept perfectly quiet in the recum- 
bent position as in all other forms of acute heart trouble, and milk or 
other bland food given. Tumultuous action may be controlled by an 
ice-bag over the heart. Small doses of morphin or codein may be 
employed to quiet and strengthen the heart's action, to control pain, 
and relieve restlessness. If the heart is weak and unsteady, strychnia, 
digitalis, or alcohol may be employed. Where effusion is extensive 



422 DISEASES OF CHILDREN. 

enough to seriously embarrass the action of the heart, aspiration 
has been tried, but with doubtful results. We have seen a case of 
sudden death due to a slight puncture of the heart muscle where 
this operation was employed. Rheumatism if present, or the original 
causative disease, must be treated in connection with the measures 
aimed at the pericarditis. 



SECTION IX. 

DISEASES OF THE BLOOD AND DUCTLESS 

GLANDS. 



CHAPTER XXX. 
DISEASES OF THE BLOOD. 

Glossary. 
Corpuscular Elements. 

Erythroc^^tes red cells. 

Leukocytes white cells. 

Poikilocytosis variations in shape of red cells. 

Normoblast nucleated red cell of normal size. 

Microblast nucleated red cell of small size. 

Megaloblast nucleated red cell of large size. 

Leukocytosis (or hyperleukocytosis) : increase in total number of 
white cells (more than 12,000) usually implies a polynucleosis. 
Leukopenia: decrease in total number of white cells (below 6,000). 
Polynucleosis : relative and absolute increase of the polynuclears. 
Lymphocytosis : relative and absolute increase in lymphocytes. 
Eosinophilia: relative and absolute increase in eosinophiles. 

Blood. 

Blood consists of a clear yellowish fluid, the plasma, in which 
float the cellular elements or corpuscles, the red cells giving to blood 
its characteristic color; the white cells or leukocytes act as phagocytes, 
and the blood plates are the product of degenerating leukocytes. 

Normal blood contains the following number of cells and blood- 
plates to the cubic millimeter. 

Erythrocytes 4,500,000 to 5,000,000 

Leukocytes 7,500 

Plates 150,000 to 300,000 

The color of blood is due to the presence of hemoglobin, an 
organic compound of iron. When of normal intensity, this color is 
given as 100 per cent. The color-index of a specimen of blood is 
obtained by dividing the per cent, of hemoglobin by the per cent, of 
red blood-cells. Normally, the color-index is ^^^^fp^: = 1 . 

The specific gravity of blood is highest in the new-born and during 
the first week or two falls to its lowest point. It remains low during 
the first two years of Hfe, averaging 1.050 to 1.055, then gradually 

423 



424 DISEASES OF CHILDREN. 

increases as puberty is reached. In adults the specific gravity is 
about 1.059. The specific gravity varies directly with the amount of 
hemoglobin present. 

Red blood-cells (erythrocytes) are most numerous per cubic 
millimeter in the first twenty-four hours of life, Hayem estimating 
the number to be 5;900,000. This number gradually falls during the 
days in which the infant loses weight. About the seventh day the 
average number per cubic millimeter is 4,500^000. This is. the average 
number of cells throughout childhood. Hayem is also the authority for 
the statement that early ligation of the funis reduces the number 
of red blood-corpuscles about 500;000 per cubic millimeter. 

Trifling causes in infancy and childhood result in marked changes 
in the red blood-corpuscles in number^ size, and shape; hence poikilo- 
cytosis and anemia are common. 

The red blood-cell is a biconcave disk, non-nucleated, varying 
greatly in diameter, 3.3 micromillimeters to 10.3 micromillimeters 
having opaque yellowish rims and nearly transparent centers. In 
adults they show a marked tendency to cohere by their flat surfaces 
forming long rows (rouleaux), though in infancy this property is much 
less marked. 

Nucleated red cells are not normally found in infants. In 
prematures they may be found for three or four days. There are 
three varieties of nucleated red cells: (1) Normoblast which re- 
sembles a normal red cell in all particulars except that it is nucleated; 
(2) Megaloblast — a large cell 10 micromillimeters to 20 micro- 
millimeters in diameter — seen only in severe anemias; (3) Microcyte 
which is smaller than the ordinary red cell; this form is rare. 

White blood-corpuscles (or leukocytes) vary in size from the 
size of a red cell to two or three times that size. In the fresh state 
the larger ones present ameboid movements if kept at body tempera- 
ture. In stained specimens the following forms may be recognized. 
(1) Polynuclears (or polymorphonuclear neutrophilic leukocytes); 
these constitute about two-thirds of all the white corpuscles in normal 
adult blood. In infancy, they occur in about 18 to 40 per cent. 
Stained by Wright's method, the nucleus takes on a deep navy-blue 
color. The nucleus is very irregular in shape, no two being alike. 
The protoplasm stains pink. The average size of these leukocytes is 
13.5 micromillimeters. 

(2) Lymphocytes, stained by Wright's method, show a small 
oval nucleus about the size of a red cell and stain deep blue; around 
the nucleus is a narrow rim of protoplasm which stains a light blue. 
At birth, the lymphocytes comprise about 40 to 60 per cent, of the 



DISEASES OF THE BLOOD. 425 

total number of leukocytes; lymphocytes vary in size from that of a 
red cell to two or three times this size, and so are named large or small. 
In the large variety, the nucleus may be placed eccentrically or in- 
dented, and the protoplasmic rim may be much wider than in the small 
ones. The average size of large lymphocytes is 13 micromillimeters; 
of small ones 10 micromillimeters. 

(3) Eosinophiles also have polymorphous nuclei of much looser 
structure and larger granules than the polynuclears. With Wright's 
method the nucleus stains a light blue or lilac and the granules a 
brilliant pink, the protoplasm staining a pale blue. The average size 
of eosinophiles is 12 micromillimeters. 

(4) Mast cells are about twice the size of a red cell, i.e., 15 micro- 
millimeters. The nucleus is usually polymorphous. Large granules 
(staining dark blue or almost black) lie over and around the nucleus 
and along the margins of the cell. 

(5) Myelocytes occur only in pathological conditions. These are 
bone-marrow cells, and are the forerunners of the polynuclear cell. 
It is a large cell, the average diameter being 15.75 micromillimeters; 
it differs from the large lymphocytes in having granules; it differs 
from the polynuclears only in the shape of its nucleus w^hich is oval 
and not broken up and which is in close contact with the cell wall for 
a large portion of its extent, i.e., if egg-shaped it is placed eccentrically. 

According to Hayem, the number of leukocytes per cubic milli- 
meter during the first forty-eight hours of life averages 18,000; falls 
to 7,000 for the third and fourth days; and averages 9,000 to 11,000 
after the fifth day. The counts of Schiff, Orunsky and Rieder run con- 
siderably higher than this. The following table (by Wile) gives the 
relative percentage of polynuclears and lymphocytes in the blood 
during the first ten years: 

Age in 
years 

1 

2 

3 

4 

5 

6 

7 

8 

9 
10 



Polynuclear 




neutrophiles 


Lymphocytes 


35% 


53% 


38% 


51% 


42% 


47% 


47% 


41% 


52% 


39% 


52% 


37% 


53% 


35% 


54% 


33% 


55% 


31% 


60% 


30% 



426 DISEASES OF CHILDREN. 

Leukocytosis (or hyperleukocytosis), i.e., an increase in the 
number of white blood-corpuscles per cubic millimeter, is present in 
the following pathological conditions: Pneumonia, diphtheria, per- 
tussis, scarlet fever, erysipelas, rheumatism, acute rickets, septic and 
cerebrospinal meningitis, and in pus cases, such as appendicitis, 
peritonitis, empyema, osteomyelitis, and acute abscess. In the above 
conditions the increase of cells is in the polynuclears and is known 
as polynucleosis. Leukocytosis is also physiological; e.g., in the 
new-born, after exercise, after a cold bath, and after a full meal; in this 
latter condition the count may be increased 33 J per cent. 

Leukopenia is a state of diminished leukocyte count, and occurs in 
typhoid, measles, influenza, malaria, tuberculous inflammations and 
gastroenteritis. 

Lymphocytosis is an increase in the number of lymphocytes, and 
occurs in syphilis (congenital), scurvy and splenic disease. 

EosiNOPHiLiA, an increase in the number of eosinophiles, occurs 
in leukemia, chronic skin disease, and in patients infected with intes- 
tinal parasites, particularly trichina. 

Blood-plates (or plaques) are best seen in fresh-blood prepara- 
tions. They are very small, round or oval bodies, about 2 to 3.5 
micromillimeters in diameter. In a few seconds they lose their 
rounded form and become spinous, and ultimately very thin filaments 
of fibrin are seen starting from their angular projections. Their 
functions are not known. 

Anemia. 

A decrease in the amount of hemoglobin produces a state known 
as anemia. The decrease may be in the total amount of blood, in the 
total number of corpuscles, or in the coloring matter of the red cells. 
Alterations in the number of leukocytes do occur in anemic states, 
yet these changes cannot be regarded as factors in the process. 

Simple or Secondary Anemia. 

These anemias are more often secondary to some of the severe, 
acute, or constitutional diseases, as gastroenteritis, syphilis, rickets, 
tuberculosis, nephritis, pneumonia, etc. Bad hygienic conditions 
and unsuitable food are often responsible and occasionally fatal. 
The nurshngs of diseased mothers are especially liable to anemia. 
Loss of blood from any cause is serious in early life, and the resulting 
anemia occasionally persists. The parasites and the toxemias produce 
anemias of this type. 



DISEASES OF THE BLOOD, 427 

Pathology. — The red blood-corpuscles are diminished in number, 
sometimes decreased to a million and a half or less. The hemoglobin 
is lowered to 30 per cent., but we have not too rarely had an estimation 
of 10 to 15 per cent. Irregular forms are seen in the severe types. 
Leukocytosis in our experience is more often observed than absent 
in early life. 

Symptomatology. — Languor, anorexia, pale or blanched mucous 
membranes and sallowness of the skin is usually present. Con- 
stipation is the rule. The gastrointestinal tract is early disordered. 
Later the child tires easily and becomes dyspneic on exertion. The 
extremities are cold. The pulse is soft. The heart action is rapid and 
hemic murmurs are heard over the base and in the neck. The sleep 
is broken, and the temperament changes. While there is usually a 
steady loss of weight, augmentation may follow in aggravated cases of 
edema. 

The spleen and liver may be found to be enlarged or enlarge after 
some weeks of illness. These children are prone to intercurrent 
affections and easily succumb to a pneumonia or gastroenteric 
infection. 

Differential Diagnosis. — Lymphatic leukemia must be dis- 
tinguished if there is splenic Iwpertrophy present. The more intense 
blood picture with its varied forms establishes the diagnosis together 
with the slower and more protracted course resisting ordinary 
treatment. 

In the pseudoleukemia of infants (von Jaksch) we have a 
marked leukocytosis with splenic and hepatic enlargement coupled 
with a hj^pertrophy of the lymph nodes. 

Prognosis. — The etiological factor and the intensity of the 
leukocytosis present must be taken into consideration in framing the 
prognosis. A low red blood-cell count, reduction of the hemoglobin 
to below 30 per cent., coupled with a high color-index, are unfavorable 
features; otherwise the prognosis is good. 

Chlorosis. 

This is an anemia characterized pathologically by a lowering of 
the hemoglobin without a marked decrease in the number of red cells 
and clinically by a greenish-yellow color of the skin. 

Etiology. — Girls at the age of pubertj", especially those who work 
in factories, or those who have deficiency of fresh air and sunlight are 
liable to chlorosis. Boys are occasionally affected. The stress of 
school duties and early social life predispose in the wealthier classes. 



428 DISEASES OF CHILDREN. 

Pathology. — Hemoglobin as low as 20 or 30 per cent, is com- 
monly observed. The red cells themselves are somewhat below nor- 
mal and the color-index is lowered. The leukocytes remain normal, 
unless complications are present. 

Symptomatology. — A striking pale green color of the skin, with 
pale mucous membranes, in a well-nourished girl who complains of 
languor and who has a capricious appetite are symptoms strongly point- 
ing to chlorosis. The blood examination will confirm the diagnosis. 
The disease runs a chronic course, and any of the following symptoms 
may be noted before the disease is arrested. Shortness of breath, 
hemic murmurs at the base of the heart and in the large vessels in the 
neck. There is some edema of the finger- j oints. Rapid heart action 
with palpitation, gastric hyperacidity, constipation, and headache are 
quite common. Percussion may show an enlargement of the heart to 
the right. The temperament changes, the patient becoming irritable, 
fussy, or even hysterical. 

Diagnosis. — A careful examination should be made to exclude 
tuberculosis (see Tuberculin Tests), gastric ulcer^ and the status lym- 
phaticus. The movements should be examined for the ova of the in- 
testinal parasites. 

Prognosis. — This is good if radical changes are made in the daily 
life of the patient and complications can be excluded. The disease does 
not react as readily to iron therapy as other anemias and runs a more 
prolonged course. 

Pernicious Anemia. 

This is rare in early life. The characteristic blood changes es- 
tablish the diagnosis. The red blood-corpuscles are reduced in 
number; megaloblasts, poikilocytosis, polychromasia, normoblasts 
and megaloblasts with myelocytes are found. The hemoglobin 
content is considerably reduced. The color-index is high. The 
leukocytes are low and the lymphocytes relatively increased. The 
spleen, liver, and glands are not hypertrophied. As the symptoms, 
course, and treatment do not differ from those in adults, they have 
been omitted, the blood picture being presented for purposes of differ- 
ential diagnosis. 

Leukemia. 

This is an uncommon disease in infancy and childhood, charac- 
terized by a great increase in the white blood-cells and changes in the 
spleen, bone-marrow, and lymph nodes. 

Etiology. — In early life syphilis, rickets, malaria, and the chronic 



DISEASES OF THE BLOOD. 



429 



affections in general are regarded as the possible causative factors. 
Whether there is a specific infection, as has been claimed; is still 
unsettled. 

Pathology of the Blood. — Two forms are distinguished; the 
myelogenous or splenomyelogenous leukemia and the less common 
lymphatic form. These are differentiated by their blood picture. 

Splenomyelogenous Form. — The white blood-cells are enor- 
mously increased — 100,000 to 500,000. Among these the myelocytes 

are found in large numbers. 
The polynuclear neutro- 
philes are relatively in- 
creased. There is an in- 
crease in the large mono- 
nuclears, the polynuclear 
and mononuclear eosino- 
philes. The mast cells may 
be found in considerable 
numbers. 

Lymphatic Form. — ■ 
The lymphocytes are enor- 
mously increased, forming 
nearly the whole percent- 
age of white blood-cells. 
Myelocytes and mast cells 
are sometimes found. In 
both forms there is a 
diminution in the amount 
of hemoglobin and in the 
number of red blood-cells 
with the presence of a few 
normoblasts. 

Symptomatology. — The 
onset may be acute, but a 
slow insidious onset is the rule. The pallor of the skin and mucous 
membranes with digestive disturbance may be the first symptoms 
noticed, or a sudden hemorrhage from the nose or blood in the stools 
may first attract attention. Vomiting and diarrhea become more 
and more frequent. Falls easily cause ecchymotic areas. The ab- 
domen is tympanitic and protuberant, and in one of our cases this 
was the first symptom to attract the mother's attention. The spleen 
is found enlarged and may touch the crest of the ilium. It may be 
tender on palpation. 




Fig. 109, — Leukemia; markings show 
enlargement of liver and spleen. 



430 DISEASES OF CHILDREN. 

The lymph nodes are quite generally involved, especially the 
cervical group. On rectal examination the mesenteric nodes are 
found palpable. Even the lymphoid structures in the nasopharynx 
are hypertrophied. The liver is found enlarged and assists in making 
more striking the general abdominal enlargement. As the disease 
advances, dyspnea, rapid heart action, and obstinate constipation 
are in evidence. The child becomes somnolent, refuses food, and 
dies of exhaustion. 

Prognosis. — It is a fatal disease in the pure types. 

Pseudoleukemia of Infants. 

(von Jaksch's Anemia). 

There has been and still is much diversity of opinion with regard 
to the disease having a distinct entity. We have had cases that 
conformed quite closely to von Jaksch's description and which seemed 
to develop from a long-continued severe anemia. The disease is 
characterized by a grave anemia with leukocytosis, enlargement of 
the spleen, liver, and lymph nodes. 

Etiology. — Infants who have had secondary anemias or who 
have rickets and syphilis are predisposed. 

Pathology. Blood. — The red blood-corpuscles are diminished to as 
low as two millions. Microcytes, megalocytes, and poikilocytes are 
found. Nucleated red cells, normoblasts, and megaloblasts may be found. 

The white blood-cells are proportionately increased up to 50,000 
or more. The differential count shows an increase in the mononuclears 
and polynuclears. The eosinophiles may also be increased. Myelo- 
cytes are seen, but are few in number. 

Symptomatology. — The infant is extremely pale, sallow, or cachec- 
tic. Slow but progressive emaciation is the rule. The infant shows 
little or no interest in its surroundings. The appetite is small and 
intestinal indigestion is frequent. The cervical lymph nodes are 
palpable and the liver and especially the spleen are enlarged. The 
spleen is easily palpable, feels hard, and it is not painful. The infant 
may die of exhaustion or a complicating bronchopneumonia. 

Differential Diagnosis. — From leukemia it is sometimes with 
difficulty differentiated, but the lower leukocyte count, the scarcity of 
myelocytes, the less pronounced hepatic and lymph node hypertrophy 
will aid in classifying the disease. 

Prognosis. — This must be regarded as a grave blood disorder. 

The principal anemias are tabulated in the following chart with 
the blood conditions briefly enumerated: 



DISEASES OF THE BLOOD. 



431 



.2 

"2 

o 

m 


Generally greatly re- 
duced, about 2 mil- 
lion. 


Mcgalocytes fre- 
quent, color usually 
not diminished. 


Poikilocytosis always 
extremely pro- 
nounced. 


Generally 20-4 0%, 
relatively higher in 
excess of corpuscles 




>^ 

03 
1 

< 


Nearly always pres- 
ent and more nu- 
merous than nor- 
moblasts. 


2 2 


O 

-^ 2 

•2 2 
2 ^ 

Q 






1 

> 

s 


Diminished ])r()portionately to or 
greater than the corpuscles 


p 

.2 

"-+3 
o 

g 

I 

o 
c 

o 
C3 
<u 
O 


03 


< 


>5 

U^ 

c3 "5 

11 

^ in 

Si 

1— (^ 


1 

1^ 


c 

c3 
> 




o 

s 

1— I 


More numerous in 
all degrees than 
in any other dis- 
ease. 


t 

o: 




Pseudoleukemia 
(von Jaksch) 
Splenic anemia 


2 


O 
N 

cr 
2 


"o 

o . 

It 


£ ^ 

03 =3 




Numerous, and 
show karyokine- 
sis. 


Sometimes found, 
especially if se- 
vere. 


.2 

w 

2 


Usually diminished, 
rarely under 2 mil- 
lion. 


Diminished in size. 
Microcytes frequent. 
Paler in color. 


2 

13 

It 

o a 
-^ X 

r 


Relatively greater di- 
minution than num- 
ber of corpuscles. 


Xf 

> 

< 


■i 


Present in severe cases 
generally in small 
numbers. 


13 

■+^ 
X 

o 

m 03 
< 




1; 


^5 

'o 


3 


1 

2 
m 




) 


l-H 

o 
'o 




c 
2 

O 




m 

XT. 

o 


^ 



432 



DISEASES OF CHILDREN. 





1 

'a 


1 

;=i 03 


"S 

m 
P 


A very large percent- 
age frequently pre- 
sent. 


-6 

03 

-^^ 




0) 


1—1 




.2-J 

l! 


^ ^ =« ^i 

a2X! T3 

^ a?; 


>> 

si 




a 

P 


cu 

o3 

a 




• 
• 

03 
P^ 




;- 

11 

"a 


CD 

a^ 


1 

'a 

"a; . 


'a 
> 

'a; 


a&^ • 


-6 






• 

• 

"a 
P4 




Pseudoleukemia 

(von Jaksch) 
Splenic anemia 


S 

h 


.a 

aj o3 


73 
0) 

c3 


-^3 




03 





^^ pi 03 


.1:5 

d 


a 


i 

bjO «2 

2d 

d ^ 
.2 
'S > 




o 

6 


C3 

a 






> 

"a 
0- 

a 
.£ 

a 

c 
a: 


■5 

1 



.a 


a; 

ga 


a 

a; 



73 

■a 


00 




d 
.2 

1 

1— 








a 

1 

;>> 





V 

> 

> 




XT 

%- 

J. 
> 

p- 


■> 


1 
> 

1 


■J 




bj 


) 


d 



73 
d 

d 








DISEASES OF THE BLOOD. 433 

Treatment of the Anemias. 

The general management of these cases is of greater importance 
than the administration of drugs. The causes which have produced 
the anemia may or may not be clear, but the majority of cases are in 
all events benefited by a regulation of their daily life. If the causa- 
tive agent, as parasites, is found, treatment should be directed to- 
ward its removal. Sunshine and fresh air coupled with an easily 
assimilated diet as rich in proteids and organic iron as possible, should 
be considered as necessities for all the anemias. 

Aerotheraphy may be limited by the circumstances as in the case 
of the poor city child, but five hours a day in the open air can always 
be obtained even in the winter months by using the child's room, the 
roof, or the parks. 

The children are more benefited when removed to the country. 
If the child has been attending school, this should be discontinued 
and the amount of exercise curtailed. Rest in bed is necessary for 
the severe cases, but this should not preclude sun baths and fresh-air 
treatment. If possible the child should be cared for and entertained 
by one person so as to avoid undue excitement or fatigue. 

A bottle-fed infant shovild gain in weight and strength if the 
formula is suitable to its requirements. If assimilation is at fault 
a wet-nurse may be required, or such changes and additions should 
be made to the food as will at least temporarily promote the digestive 
capacity. (See article on Infant Feeding.) 

Older children should have an individual diet list prepared for 
them which will contain especially such articles as fresh raw milk, 
eggs, vegetables, rare meats, and fresh fruits. (See Diet Lists, p. 196.) 
Spinach, yolk of egg, and the legumes contain organic iron in largest 
quantities, and, it is desirable that the deficiency in iron should be 
made up from the natural foods rather than iron preparations. 

Drugs. — In chlorosis the iron preparations are of distinct value, 
especially when given with a nutritious diet and baths. Many of the 
anemias are benefited by the scale preparations, especially the 
citrate of iron and ammonia and the bitter wine of iron. Several 
trials may be required to find the preparation of iron best suited to 
the individual case. The various peptonates often do well, as they are 
easily tolerated by the stomach, but other cases will apparently do 
better on the old tincture of the chlorid of iron, well diluted and given 
through a tube. In older children, Blaud's pill will often do good 
service. Fowler's solution should be given in addition to the leuke- 
mias and in pernicious anemia, beginning with one drop three times 

28 



434 DISEASES OF CHILDEEN. 

a clay well diluted and gradually increasing to the physiological result, 
care being taken not to produce symptoms of arsenical neuritis. Cod- 
liver oil is a valuable addition if it is well borne and does not produce 
an aversion to the ordinary diet. 

We have used the X-rays in selected cases of splenic leukemia, but 
the results which at first seemed promising do not warrant its general 
use. 

Purpura. 

In this condition subcutaneous hemorrhages, petechial or ecchy- 
motic in type, appear spontaneously and form one of the symptoms 
of a disease. Different names have been applied varying with the 
location and extent of the hemorrhages. 

It is known as purpura simplex when the hemorrhages occur into 
the skin only, and purpura hemorrhagica when bleeding. takes place 
into the mucous membranes or internal organs. 

Etiology. — 'Any infectious process at any time during its course 
may be accompanied with purpura. It especially occurs in children 
with scarlet fever, variola, measles, cerebrospinal meningitis, and 
with septic processes in any organ. 

Pathology. — Hemorrhagic exudates may be found varying with 
the type of the disease either in the skin, mucous membranes, or 
internal organs, or in all of these situations. The spleen is enlarged 
in those types occurring with marked infection. The study of the 
blood has thus far thrown no light on the pathology of the disease. 
Further study of the adrenal bodies, which sometimes show large 
hemorrhages, may explain the etiology of the disease and prove 
whether it is an infectious process, a pathological change in the 
arteries themselves, or whether it is due to vasomotor changes that 
allow the hemorrhage to take place. 

Purpura Simplex. — The purpura may appear suddenly in a child 
that is apparently well, but as a rule it is preceded by prodromal 
symptoms resembling those of intestinal disturbance. There may be 
lassitude, loss of appetite, even nausea or vomiting. The stools may 
be slimy from improper digestion, and a low grade of fever is present 
in older children, but little or no variation is noted in infancy. The 
tibial surfaces are usually first involved, the hemorrhagic areas varying 
greatly in extent in different subjects. The color soon changes from a 
purplish-red to a dark, mottled, bluish-black. There is no pruritus 
nor pain on pressure over these areas. Indefinite muscle or joint 
pains are complained of, but localized with difficulty. 

In cachectic or marasmus infants it is not uncommon to see these 



DISEASES OF THE BLOOD. 



435 



hemorrhagic areas appear over the abdomen or extremities. In any 
long-standing or exhausting disease in the early months of life, purpura 
may appear and must be regarded as of serious import. 

In older children, however, purpura simplex tends to recovery, 
although relapses sometimes occur when the outlook seems most 
bright. 

Purpura Hemorrhagica. — In contrast to the simple form, this is a 
much more serious condition with a rather severe train of symptoms. 
After a few days of indisposition, with nausea and vomiting, fever 




Fig. 110. — Purpura hemorrhagica. 



appears ranging from 100° to 104° F., with prostration out of propor- 
tion to the symptoms. At the same time that the hemorrhages appear 
in the skin, there may be bleeding from the nose or mouth. Hemor- 
rhages in the alimentary tract may occur and are noted by finding 
blood in the vomitus or in the stools. The fact must not be forgotten, 
however, that the blood may be swallowed and later appear in the 
vomitus or stools. Blood in the urine usually occurs in the beginning, 
but ceases when the child is put at rest. Localized areas of edema 
may be present and, as a rule, correspond to, although greater than, 
the hemorrhagic areas. Pain referred to the gastric region, headache, 
and anorexia are quite common symptoms which persist in spite of 
treatment. Sleep is broken, and delirium, especially at night, may 



436 



DISEASES OF CHILDREN. 



occur. Coma resembling that of the typhoidal state occurs in the 
severe cases and may persist until a fatal issue takes place. 

Henoch's Purpura. — This symptom-complex, occurring as a rule 
in childhood, was first described by Henoch. The symptoms refer- 
able to the skin consist of a purpura of varying degree, often accom- 
panied by an exudative erythema and urticaria or a locahzed edema. 
Besides the above manifestations, there are lesions in one or more 
joints which resemble rheumatic fever. Colicky pains, with vomiting 




Fig. 111. — Henoch's purpura. 



and diarrhea, are nearly always present, but as a rule are not of long 
duration. As in purpura hemorrhagica, there may be hematuria or 
hematemesis. Albumin is generally found in the urine. Recur- 
rences are frequent and succeeding attacks may show wide varia- 
tions in the symptoms. 

Schonleins Purpura. {Purpura Rheumatica.) — This form is char- 
acterized by a polyarthritis with the symptoms of rheumatic fever and 
purpuric hemorrhages. Circumscribed edema may be present. A' 
variable amount of temperature occurs with the arthritis. Albumin 
is generally found in the urine. 

Purpura Fulminans. — A very rare but fatal form of purpura is 
designated as a fulminant type. The onset is sudden, occurring with 



DISEASES OF THE BLOOD. 437 

high fever, convulsions or chills, vomiting, and marked prostration. 
The purpuric eruption rapidly spreads over the whole body. The 
urine is scant and contains albumin. It most frequently occurs in 
children under five years of age, and what was formerly known as 
malignant or black scarlet fever and measles probably belong to this 
type. Hemorrhages into the adrenals have been recorded. 

Diagnosis. — The diagnosis of purpura is usually easity made from 
the hemorrhagic nature of the lesions which do not disappear upon 
pressure. It is to be distinguished from infantile scurvy in which 
there are present swollen, spongy, bleeding gums, and articular pain 
combined with a long history of cooked food. 

Prognosis. — In certain forms, as the simple and rheumatic, the 
prognosis is favorable, although it may persist for several weeks. 
Hemorrhagic purpura and Henoch's purpura have sometimes been 
attended with fatal results. The fulminant type is always dangerous 
to life. 

Treatment. — This must necessarily be directed to the under- 
lying cause when this is known. Rest in bed with a carefully regu- 
lated diet, including raw fruit juices, is indicated. The fluid extract of 
ergot internally or 5 minims of a toVo" adrenalin solution hypoder- 
matically may be given if the hemorrhages are profuse. In convales- 
cence the tincture of the chlorid of iron is important. 

Hemophilia. 

Hemophilia is an hereditary blood disorder characterized by a 
tendency to. inordinate bleeding from the vessels following a trauma, 
or spontaneously from the capillaries into the tissues. 

It is almost invariably transmitted through the mother, who 
herself may not have been a bleeder. The male offspring (the first 
born often escaping) is affected in the proportion of eleven to one of 
the female. The male may again transmit the disease through his 
daughter. 

No characteristic blood changes or histological peculiarity of the 
vessels has been found. Coagulation is always retarded. The 
hemorrhages occur most frequently from the nose, mouth, genital 
organs, and lungs. Some trauma to these parts may be the first notice 
of the diathesis or the fact that slight, almost imperceptible blows 
produce subcuticular hemorrhages. Following a fall there may be 
internal hemorrhage or bleeding into a joint that may produce dis- 
ability or subsequent anchylosis. Death has occurred from uncontroll- 
able hemorrhage following circumcision or the extraction of a tooth. 



438 DISEASES OF CHILDREN. 

Treatment. — Marriages in the families of bleeders should be con- 
trolled or at least due warning of consequences given. 

Subcuticular hemorrhages are sometimes controlled by absolute 
rest with ice applications and compression. Adrenalin 1-1,000 or 
1-500 adrin solution may be directly applied. Stypticin in doses of 
gr. i offers some hope of control. The gelatin solutions for subcu- 
taneous use are to be deprecated, as they may be carriers of tetanus 
infection. Warm or rather tropical climates are the safest for the 
hemophiliac. 



CHAPTER XXXI. 
DISEASES OF THE DUCTLESS GLANDS. 

The Thymus. 

This small, ductless gland, of epithelial origin, consists of two lobes 
coming in contact in the median line. It is located during its greatest 
development partly in the lower part of the neck and partly on the 
anterior mediastinum, extending from the lower edge of the thyroid 
above to the fourth costochondral articulation below. It is thus in 
relation with the trachea above and the great vessels and pericardium 
below. It is largest during the first two years of life and then atro- 
phies, but occasionally it persists longer and may last until puberty. 
In the course of atrophy it disappears from the neck and remains 
behind the manubrium. Various authorities disagree as to its normal 
weight. From 14 to 20 grams are said to be the average weight 
during infancj^, but Boviard finds it much smaller than usually stated. 
From 100 observations made on the normal size of the thymus in early 
life, he found it averaged not over 3 grams, in weight. The histo- 
logical structure of the thymus is similar to that of lymph-glands, and 
it probably functionates as a blood-forming organ. 

Enlargement of the Thymus. 

Hypertrophy of the thymus may produce grave effects apparently 
from pressure. Two possible explanations may be offered — first, 
that the enlarged thymus pushes on the trachea and thus embarrasses 
breathing; second, that dyspnea may be caused by pressure on the 
phrenics or pneumogastrics. It is-, however, difficult to prove the lat- 
ter. Laryngismus stridulous and various forms of dyspnea, some- 
times called 'thymic asthma," have been referred to the enlarged 
thymus. The symptoms may eventuate in sudden death. 

The diagnosis of enlarged thymus by physical signs is rarely 
made positively during life. It may occasionally be palpated by 
deep pressure over the top of the sternum and there may be dullness 
on percussion behind the upper part of the manubrium extending 
down from both lateral borders of the sternum. The area of dullness 
on the sides of the sternum may be unsymmetrical. 

439 



440 



DISEASES OF CHILDREN. 




Fig. 112. — Marked enlargement of the thymus gland with its relations; 
from an infant, 7 months old. 



:isSi 



DISEASES OF THE DUCTLESS GLANDS. 441 

Status Lymphaticus, 

By this condition is understood a lowered vitality seen in con- 
nection with enlarged thymus and a general hyperplasia of the lym- 
phoid tissue of the body. Sudden death from cardiac paralysis and 
asphyxia may ensue under anesthesia or from any intercurrent disease 
or irritation. Enlargement may be noted of the superficial and deep 
lymph nodes of the neck, of the follicles at the root of the tongue, 
of the tonsils, of the adenoid tissue at the vault of the pharynx, and, 
on autops}^, of the lymphoid structures of the stomach and bowels. 
There may be some enlargement of the spleen with hypertrophy of 
the Malpighian bodies. There may likewise be a proliferation of the 
lymphoid tissue of the bone-marrow. Drs. Musser and Ullom report 
the pathological findings to be practically constant in eighteen cases 
of status lymphaticus collated from the literature of the subject, 
consisting of an enlarged thymus, spleen, lymph glands, Peyer's 
patches, tonsils and pharyngeal tissue. While these conditions were 
not reported in every case, the enlarged thymus, spleen, and some of 
the lymph-glands were constantly found. Cloudy swelling of the 
liver and kidney were also fairly constant lesions. German path- 
ologists, especially Virchow, have noted a lack of development of the 
heart and arteries. Thus the heart may be small and the aorta narrow 
and thin-walled. With this may be associated a lack of development 
of the sexual organs sometimes reaching the condition of infantilism. 
Varying grades of rickets, with resulting mild or severe bony defor- 
mities, are seen in a large number of (3ases of status lymphaticus. These 
children may show a fair amount of fatty tissue, but are usually 
anemic. Chlorosis or hemophilia may also exist. 

It is very probable that the disastrous results so often seen in 
status lymphaticus are due to an autointoxication from a sort of 
lymphotoxemia having its source in the lymphatic tissues of the body. 
The importance of recognizing the condition is very great not only in 
respect to anesthesia, but for guarding the prognosis in any intercurrent 
mild or severe disease and as an explanation of certain cases of sudden 
death without any known cause. 

The diagnosis often cannot positively be made, but children or 
young adults with bony evidences of rickets, with much enlarged 
tonsils and adenoids, with generally hypertrophied lymph-glands, 
.with the male genital organs or breasts undeveloped in the older 
subjects, together with an absence of pubic hair, should be considered 
as possible subjects of status lymphaticus. 

In young subjects, attacks of laryngospasm, in conjunction with 



442 DISEASES OF CHILDREN. 

a number of these stigmata will greatly strengthen the diagnosis. 
Congenital underdevelopment of the heart and arteries is usually 
accompanied by smallness of the surface arteries and a small pulse. 

The treatment consists in careful hygienic oversight, especially 
as regards food^ fresh air, and warm clothing. Cod-liver oil and the 
syrup of the iodid of iron may be given. The hypertrophied tonsils 
and adenoids must be early removed, but without the administration 
of an anesthetic. 

Diseases of the Spleen. 

The spleen is not uncommonly found to be enlarged in infants 
and children. Its elastic, distensible structure makes it peculiarly 
susceptible to enlargement, especially from congestion, infectious, 
blood, or constitutional disorders. 

Its upper border lies on a line with the ninth rib, its lower border 
reaching to the eleventh rib. It is a safe rule to say the spleen is not 
enlarged if it cannot be palpated below the ribs. The position for 
palpation should be that described on page 44, Fig. 10. 

Inflammation of the Spleen. 

This occurs, as a rule, from a neighboring process or from trauma. 
Perisplenitis may occur in syphilis, tuberculosis, peritonitis, and 
injuries. Older children may refer their pain accurately to the splenic 
region. In some cases a friction rub is distinctly felt. With the 
stethoscope a coarse friction sound, not unlike that in pleurisy, can 
be heard. 

Chronic Passive Congestion of the Spleen. 

This is seen in connection with enlargement of the liver, tuber- 
culosis, and in cardiac affections. 

Other Enlargements of the Spleen. — Sarcoma, although rare, 
has been observed as a primary condition. The tuberculous and 
syphilitic enlargements are nodular and irregular. Primary spleno- 
megaly is accompanied by enlargement of the liver and anemia. 
Hydatid cysts and abscesses have been reported, but are extremely 
rare. 

Disorders of the Adrenals. 

Reports of sudden deaths from hemorrhages into the adrenals 
have increased the importance of these structures in early life. In 



DISEASES OF THE DUCTLESS GLANDS. 443 

infants they are relatively larger, and destruction of their function, 
whatever it may be, is attended with serious results. 

Hemorrhage into the Adrenal. — The symptoms come on 
suddenly not unlike an acute infection. There may be vomiting and 
diarrhea with acute abdominal pain and, in some instances, a pur- 
puric rash. The pulse is weak, the pallor is marked, and coma or 
convulsions may usher in the rapidly fatal endings. 

Addison's Disease. 

This is extremely rare in early life and is accompanied by the 
same symptoms; that is, slow progressive cachexia and bronzing of 
the skin as in adults. In nearly all cases tuberculosis of the structure 
is found on postmortem examination. 

The course is slow, sometimes extending over years, and the prog- 
nosis invariably bad. 

Treatment. — Restriction of muscular exercise and the general 
treatment suitable for the tuberculous is indicated; the feeding of 
adrenal products, as the desiccated extract or glycerinated extract, 
may be employed or adrenalin in solution may be given. 

Hodgkin's Disease. 

(Adenie; Lymphadenoma; Pseudoleukemia.) 

This disease very rarely occurs in children. The main features are 
painless, progressive glandular enlargement, usually beginning in 
the cervical region, and without the blood changes of leukemia; en- 
largement of the spleen and liver and a pronounced anemia; either 
tuberculosis or syphilis may be associated, but in all probability 
neither of these conditions bears any relation to Hodgkin's disease. 

Symptomatology. — The enlargements generally first appear in 
the neck. The glands slowdy but steadily enlarge. They are not pain- 
ful to the touch. The axillary and inguinal regions are later involved. 
When the general health begins to be affected it will be found that 
both the superficial and deep glands are affected. From their posi- 
tion the nodes may produce various pressure symptoms, such as dysp- 
nea or dysphagia. In the later stages pronounced cachexia develops 
with an irregular or remittent type of fever. The glands never tend 
to suppuration, although they may fuse and form large tumors. 

Differential Diagnosis. — It is distinguished from chronic adenitis 
by the history, the localization, and absence of cachexia. Tuberculin 
or the various tuberculin tests would be required to distinguish it in 



444 DISEASES OF CHILDREN. 

the absence of suppuration. Excision of a lymph node for histological 
examination is the safest course for absolute diagnosis. 

Treatment. — Thus far this has been quite unsatisfactory. Unless 
the diagnosis is made when only a few glands are involved surgical 
removal is not advisable. 

The Roentgen rays have given some good results, but this should 
only be used by those accustomed to the work. Arsenic may be given 
in large doses in the form of Fowler's solution. Out-door life at the 
seashore is to be preferred. 

Acute Adenitis. 

This is an acute inflammation of the lymph-glands producing 
hypertrophy of their structure. 

Clinically the lymphatic glands are of great importance, their 
function being to guard the circulatory system since they are obliged 
to take up, destroy, neutrahze, or at least hold in abeyance the num- 
berless bacteria which block their channels, and it is only when over- 
whelmed and overpowered by these germs that they themselves be- 
come affected. 

Recent investigations along these lines have sufficiently proved 
that inflammation of the lymphatic glands is due to absorption, from 
a more or less distant focus, of bacteria or their toxins. i 

Accepting the crude classification of inflamed glands into acute 
and chronic we find that the glands most frequently affected are 
the cervical, mesenteric, axillary, inguinal, bronchial, and mediastinal. 

The majority of children with enlarged glands have cervical 
adenitis. This is accounted for by the delicate epithelium of the skin 
of the face and neck and the mucous membrane of the mouth and the 
pharynx. These being largely exposed to irritations, to bacteria, and 
to traumatism, we find the glands easily overpowered. It is always 
necessary to seek the cause or focus of the trouble and, if possible, 
to remove it. 

Remembering that the superficial glands drain the side of the 
head and -neck, face and external ear, and that the deeper glands drain 
the mouth, tonsils, palate, pharynx, and larynx, we have a clue to the 
initial trouble. It is not to be forgotten that the primary focus may 
have cleared up or may have been apparently cured and forgotten, but 
still the glands remain enlarged. A careful history of the eruptive 
and infectious diseases must be obtained; any irritations of the scalp, 
diseases of the ear, eyes, nose, throat, gums, or teeth must be taken 
into consideration. The importance of working backward from the 



DISEASES OF THE DUCTLESS GLANDS. .445 

effect to the cause in these cases must be kept in mind. Either the 
superficial or deep nodes may be affected. Under two years of age 
the external glands are affected in the majority of cases, and they also 
have a greater tendency to undergo suppuration. When the latter is 
about to take place the gland becomes painful and tender and the over- 
lying skin is reddened. Restlessness and some degree of temperature 
is observed. As a rule, this takes place during the second week or it 
may be held in check by cold applications and result later. A spon- 
taneous discharge of pus does not occur until the entire gland has been 
disintegrated. Occasionally there seems to be no apparent cause 
except anemia and debility for the glandular hypertrophy, but here 
we have a valuable clue to the treatment. 

The glands may at first show no acute inflammatory changes; they 
grow steadily and surely, and do not easily break down. Because of 
the slow growth and painless tumor, and with no local cause'observable, 
we are justified in presuming the glands to be tuberculous. The tuber- 
culin test (page 54) should be made. Such a condition by no means 
signifies that the child has pulmonary tuberculosis, although having 
once given entrance to these germs the possibility of an extension is 
present. The cervical glands may infect the thoracic chain and thus 
infect the lungs. 

Chronic Adenitis. 

This may occur as a result of frequent attacks of acute adenitis 
or from persistent local lesions in the neighboring structures. It is 
also observed in children who are the. subjects of status lymphaticus. 
The glands must be differentiated from tuberculous lymph nodes 
or those seen in Hodgkin's disease. 

Thoracic adenitis is in greater part of the chronic type and very 
often the glands are tuberculous. Loomis has examined and found 
the tubercle bacillus in apparently normal glands. We may safely 
say that in a large proportion of tuberculous cases in children it would 
appear that the primary infection was in these structures and that, 
contrary to Parrot's law, clinical experience shows that the glands 
may be involved without local lesions in the lungs. 

In a large number of autopsies in children, we have found the 
mediastinal and bronchial lymph-glands enlarged, sometimes pressing 
on the great vessels or against the bronchial tubes. In one case per- 
foration of the cheesy bronchial gland into the adjacent lung was the 
cause of death. We cannot describe any definite symptoms invariably 
produced by these pathological glands, but occasionally we do get a 



446 DISEASES OF CHILDREN. 

persistent irritative cough caused by pressure on a bronchus or on the 
recurrent laryngeal nerve, or localized feeble breathing with sibilant 
rales due to compression of a bronchus. Percussion is unreliable, for 
the dullness may be due to the thymus. Recurrent attacks of bron- 
chitis may, however, often be traced to hypertrophied lymph nodes 
in the thorax. 

The enlarged mesenteric and retroperitoneal glands of the 
abdominal cavity may alone give sufficient evidence of the old- 
fashioned tabes mesenterica. The point of entrance of the offending 
germs in these cases is through the mucous membrane of the intestinal 
canal. If we find a general enlargement of the glands all over the body 
— a condition which Legrouz called microadenopathy, we have a 
valuable hint in doubtful cases of general tuberculous infection. On 
the other hand, the absence of hypertrophied lymph-glands and the 
enlargement of the liver and spleen is an important negative sign in 
chronic diffuse tuberculosis, provided we can rule out syphilis by the 
history of skin rashes, fissures, and the therapeutic test; for here also 
we may have enlargement of the superficial glands. The glands, 
therefore, may assist in establishing a correct diagnosis; they may 
point out by their anatomical distribution the source of their own 
infection, or they may themselves be productive of pathological con- 
ditions in adjacent viscera. 

Treatment. (Acute.) — As has been above pointed out the removal 
of the local focus of irritation is most important. If seen early the 
application of the ice bag or cold compresses may cause a subsidence of 
the process. The application of a 5 to 10 per cent, ointment of 
ichthyol is also effective. If suppuration has begun the local appli- 
cation of heat will hasten the process. Incision and drainage are 
then indicated. 

(Chronic.) — Any underlying cause as a chronic eczema, adenoids 
and hypertrophied tonsils or a sinus must be removed before treat- 
ment can be effective. 

The syrup of the iodid of iron must be given for a long period. 
The X-ray treatment has given some good results. 

Exophthalmic Goiter. 

(Gravels Disease; Basedow's Disease.) 

This condition, which is rare in early life, is due to an increase 
in the growth and activity of the thyroid gland. Our cases have 
occurred at or about the time of puberty, especially in girls of the 
neurotic type. Hyperemic goiters occurring at the time of puberty 



DISEASES OF THE DUCTLESS GLAXDS. 447 

must be distinguished from true Basedow's disease. Tachycardia is 
present in both conditions, but the exophthalmos, tremors and pur- 
poseless movements are not present. This variety often disappears 
suddenly when menstruation is well established. 

Symptomatology. — With the gradual enlargement of the lobes of 
the thyroid there may be noted symptoms resembling chorea. Nausea 
and vomiting at the sight of food may be the first symptom to call 
attention to the true condition. The child is apt to be irritable, 
easily excited and depressed if left without companionship. 

Physical examination will show a well-marked tachycardia, 
usually with a soft systolic murmur at the base. The eye later has 
a pecuhar fixed, staring look, and is covered by the upper lid with 
difficulty. 

Graefe's sign, or the difiiculty of raising the upper eyelids when 
the child is asked to look upward, is usually observed. Profuse 
diarrhea which is controlled with difficulty is rather frequent in early 
life. The sleep is disturbed, and several times during the day the 
face may become flushed and perspiration appears on the body. 

Course and Prognosis. — Rarely the course is very rapid and ends 
fatally in a few weeks. In the majority of cases the prognosis is slow, 
with steady emaciation and periods of remission. The younger the 
patient the better the prognosis. 

Treatment. — Rest in bed, both physical and mental, with a light 
milk and vegetable diet is required until the symptoms subside. 
The extremely rapid pulse may require cardiac sedatives. Ice-cold 
applications or alcohol compresses may answer. If not sufficient in 
effect, the tincture of strophanthus or digitalis may be required. The 
serum of Rogers and Beebe, of the Cornell laboratory, has proven of 
value in selected cases. The amount injected varies with the degree 
of toxicity and the duration of the disease. Galvanization with a 
mild current of three milliamperes may be used with advantage in con- 
junction with any form of treatment. Thyroidectin, a product 
derived from the blood of thyroidectomized sheep, is sometimes of 
distinct value; it may be tried and continued if the pulse and nervous 
symptoms subside. 

Achondroplasia. 

Achondroplasia (fetal chondrodystrophy) is a rare affection in 
which there is a marked disproportion between the head and trunk and 
extremities. This is due to an abnormal process of endochondral 
ossification at the junction of the epiphysis and diaphysis. The 
principal change is a defective formation of rows of cartilage cells 



448 



DISEASES OF CHILDREN. 



in the columnar zone. There often occurs an overgrowth of perios- 
teum in this region, this tissue wedging its way in between the 
epiphysis and diaphysis from the periphery toward the axis of the 
bone. These processes both prevent growth in length of the bone. 

Achrondroplasia is a congenital condition, and the features are 
evident at birth; usually the parents are undersized or dwarfed. 

The extremities are mostly affected, 
leaving the head and trunk nearly 
normal; the length of the arms and the 
legs is greatly diminished, the hands 
often reaching only to the trochanters, 
while normally they should reach to the 
knees. There is a redundancy of tissues 
around the thighs, making thick folds in 
the skin. Muscular tone is low and the 
joints are lax, consequently all these 
children are late in walking. The head 
is relatively large, the bridge of the nose 
is usually depressed, the tip of the nose 
is bulbous, the eyes are far apart and in 
the infant the tongue may be thick, this 
being due to a real hyperplasia. As a 
rule, the fontanels are late in closing; 
teething also is delayed. 

The bones are short and thick with 
enlarged epiphyses; curvature in the 
shaft of the long bones which often 
occurs is not due to softening but to 
periosteal intrusion which offers resis- 
tance to growth in length of the dia- 
physes. Frequently a marked lumbar 
lordosis is present, the sacrum being 
tilted upward and backward. Beading 
of the ribs, as in rickets, may be present. 

The hands are small and square, the fingers being short and nearly 
equal in length and blunted at the ends. The ^Hrident deformity'' 
(divergence of middle and index-fingers from ring and little fingers) 
is often noted. The mentality in these children is not affected to any 
marked degree, although they are inclined to be backward. 

Prognosis as to life is good, but such children are always under- 
sized. Organic extracts from the thyroid and pituitary glands are 
used in the treatment, although the results have not been satisfactory 




Fig. 113. — Achondroplasia 
{Bradford and Lovett). 



DISEASES OF THE DUCTLESS GLANDS. 449 

and are not to be compared in any sense to those obtained with cretins. 
For the differential diagnosis see the article on Cretinism, p. 451. 

Infantilism. 

This is a condition characterized by a retardation of bodily de- 
velopment out of all proportion to the chronological age. 

These children are always small in stature, underweight, unde- 
veloped sexually, and retain the falsetto voice of childhood. Their 
mentality, however, is usually fair and they are capable of making good 
progress when placed in school. 

Two types have been distinguished. In the Brissaud type 
the children are somewhat cretinoid in appearance, the face being 
flat and chubby, the body plump, the hair sparse and fine on the head, 
and there is an absence of pubic hair. In this type, ossification and 
epiphyseal growth maybe delayed. The juvenile state of the body 
and mind is long retained. 

The second, or Lorain type, is distinguished by the rather slender 
body and finer features, although the genitals and voice remain long 
undeveloped. The mentality is apparently unimpaired in this latter 
type. Herter has recently pointed out that in cases of infantilism 
an intestinal digestive disorder may be the etiological factor. He 
believes the Bacillus infantilis to have a direct relation to the disease. 

The intestinal bacteria are replaced by gram-positive bacilh. 
The maldevelopment is attributed to the loss of fat in the stools and 
the intolerance to carbohydrates. 

The cretinoid type reacts favorabh^ for a short time to the use 
of thyroid extract. The Lorain type is not affected by this drug, and 
we are inclined to favor Herter's suggestion to treat the disease as a 
nutritional disturbance. Gelatin is recommended as of value. The 
diagnosis, however, would need to be made very early in order to obtain 
good results. 

Cretinism. 

{Myxedema.) 

Myxedema is a disorder of metabolism, resulting from an alteration 
or absence of the thyroid body or its functions. 

Cretinism. — Two varieties are recognized: The endemic and 
sporadic (infantile myxedema). It is with sporadic cretinism that 
we are concerned in this country. The symptoms are the result of 
the complete absence of the thyroid gland. 

Etiology. — Hereditary factors, such as syphilis, rickets, and tuber- 

2Q 



IHiit 



450 



DISEASES OF CHILDREN. 



culosis in the parents, seem to favor the development of cretinism. 
The disease rarely occurs in the tropical chmates, and we have not as 
yet seen a colored cretin. 

Symptomatology. — Sometimes at the sixth month, or soon there- 
after, the mental dullness of the child is noted. It shows very little, if 




Fig. 114. 



-Hand of a cretin, showing the undeveloped carpal 
bones and blunt finsrers. 



any, interest in its parents or surroundings. Even its toys are unnoticed. 
Upon inspection, the face is found to have a stupid, vacant expression, 
the eyes are dull, the eye-lids often simulating the Mongohan type and 
are wide apart; the hair is sparse and coarse, the nose flattened, and 
the bridge sunken, the head appears large and is set upon a short 
thick neck. From the thick lips a tongue apparently too large for 
the mouth protrudes, and saliva drools from the mouth. The general 



DISEASES OF THE DUCTLESS GLANDS. 451 

stature is quite characteristic. The child is markedly stunted, the 
abdomen appears protuberant, due to the anteroposterior curvature 
of the spine. The child appears well nourished or even obese. An 
umbilical hernia is quite generally present. The arms and legs appear 
short and stumpy. The hands are spade-like and the fingers blunted; 
X-ray examination shows characteristic changes in the carpal bones. 
On palpation pads of subcutaneous fat may be felt over the upper part 
of the chest. The skin is found to be harsh and dry. The subcutan- 
eous fat does not pit on pressure. 

The fontanel may be imperfectly closed. If held erect, the 
peculiar stature and prominent abdomen are intensified. The head 
will often show a disproportion from the normal, as will the length 
of the child to its years of life (see Diagram p. 31). A cretin of 
eight or ten years may simulate in height a child of two or three 
j^ears. The temperature is usually slightly subnormal. In older 
children a history will be elicited of marked mental deficiency. The 
child does not learn to speak, often showing irritable or vicious tem- 
per, with uncleanl}^ habits as to stooling or urination. The teeth are 
very apt to become carious soon after eruption, and stomatitis is fre- 
quently observed. Untreated cases form a good proportion of the 
so-called dwarfs scattered throughout the country. 

The blood examination shows nothing characteristic; usually, how- 
ever, there is a diminution of the red blood-cells and hemoglobin. The 
above description applies to the typical cretin; however, we quite 
frequently meet cases exhibiting a mental deficiency plus some of 
the physical characteristics outlined above, but in a milder form. 
In the early months of life the condition often goes unrecognized 
because the phj^sician has not carefully enough observed and watched 
the infant. These may be classed as cretinoids. If the examiner will 
keep this type in mind, he will be more likely to diagnosticate cases in 
infancy. 

Differential Diagnosis. — Mongolian idiocy, achondroplasia, in- 
fantilism, rickets, and chronic nephritis must be differentiated from 
sporadic cretinism. 

The Mongolian idiot is small in stature and mentally deficient, 
but the distinct slanting type of eyes with the more shapely bodies and 
their willingness to go about, quite readily distinguish them from the 
cretins. 

Achondroplasia. — The large heads, the very short arms and legs, 
which are in marked disproportion to the normal body length, added to 
their fairly well developed intellect, quite readily stamp the diagnosis. 

Infantilism. — The symmetry of body and normal mental develop- 



452 



DISEASES OF CHILDREN. 






DISEASES OF THE DUCTLESS GLAXDS. 



453 



ment are strong distinguishing characteristics. However, the infantile 
voice and lack of genital development with the child-like skin, may 
occasionally lead to a mistaken diagnosis of cretinism. 

Rickets. — This condition should not be confounded, as in rickets 
the mentality is normal and the bony changes are quite characteristic, 
even when the child is dwarfed by its deformities. 




Fig. 118. — Radiograph of arm from 
Fig. 119, showing carpals. 



Fig. 119. — Cretin with acromegaly 
Age 7 years, untreated. 



In chronic nephritis the pitting of the skin and the examination 
of the urine should clear up a suspicious case. 

The therapeutic test should be applied whenever there is any 
doubt. 

Prognosis. — The importance of early diagnosis has been dwelt 
upon, as the prognosis is so much better the earlier the treatment is 



454 



DISEASES OF CHILDREN. 



instituted. Up to the age of puberty comparatively remarkable 
changes result from treatment. Young adults receive only very 
meager benefit from the treatment. Untreated cases usually suc- 
cumb to some intercurrent infection and their mentality remains 
quite stationary. 





Fig. 120. — Cretin, before treatment. 
{Dr. Long's case.) 



Fig. 121. — Same case after one 
year of treatment. 



Treatment. — Desiccated thyroid extract, if fed to cretins, soon 
produces wonderful changes in their physical and mental state. 
Thyroid extract, in large doses, it should be remembered, has a 
depressing influence on the heart and circulation and should be 
carefully given if there is any cardiac lesion. It should be given in 



DISEASES OF THE DUCTLESS GLANDS. 455 

increasing doses to infants, beginning with one grain three times a 
day, and increased slowly to fivfe grains three times a day. Older 
children may finally take twenty to thirty grains in a day if necessary 
and if no depressing effect is produced. (A case under our observation 
had so far improved as to locate the box of tablets hidden in the clock. 
He ate sixty grains in all. He became somewhat cyanotic, but 
quickly revived under the influence of stimulation.) The treatment 
must be continued in fairly large doses, until a decided change has 
been reached and further improvement does not take place. Then 
smaller doses, that is, about ten grains a week, may be necessary 
throughout life to prevent a relapse into the former condition. The 
recession of the tongue, loss of adipose, and lack of drooling are the 
first signs of successful thyroid therapy. 



SECTION X. 
GENERAL DISEASES OF NUTRITION. 



CHAPTER XXXII. 
NUTRITIONAL DISORDERS. 

Rachitis. 

(Rickets.) 

Rachitis is a general disorder of nutrition, complex in character 
which affects the growing organism, and is characterized chiefly by 
changes in the bones, Kgaments and muscles in conjunction with ner- 
vous symptoms. 

Etiology. — Although a number of theories have been advanced 
to explain the causation of rickets, none have displaced the generally 
accepted idea that rickets is a result of faulty nutrition. It is distinctly 
a disease of infancy and childhood, and generally a preventable one. 
It seldom occurs before the sixth month of life (although congenital, 
rickets is not unknown), and is rarely seen after the third year. 

In this country it is more commonly seen among the children of 
foreigners, especially the Italians and negroes. While it is undoubt- 
edly more common in Europe than with us, still the number of cases 
seems to be increasing in our large cities where the hygienic conditions 
are poor. It is most frequently seen among the children of parents 
who, themselves, have suffered from nutritional disorders or who have 
been the subjects of alcoholism or tuberculosis. The enfeebled off- 
spring of such parents are particularly liable to rickets when they live 
in badly ventilated, sunless quarters and are improperly fed. The 
food may cause perversion of nutrition because it is deficient in certain 
elements, as the proprietary foods, or because in quantity and charac- 
ter it overtaxes the digestive functions. It is rarely seen in breast-fed 
children unless the milk is deficient because of prolonged lactation, 
pregnancy, or disease. The proprietary foods and condensed milk, 
if constantly used without the addition of fats, are particulary liable 
to cause rickets. Under these conditions it may also occur among the 
better classes. 

Pathology. — The greatest changes are found in the bones. Clinical 
analysis shows that the bony structures in rickets are made up of two- 
thirds organic matter instead of one-third, as found in normal bones 
of this age. A cross section of a long bone at its junction with the 

456 



XUTRITIOXAL DISORDERS. 



457 



epiphysis shows an enlargement and an increase in the cartilaginous 
structure which is engorged and vascular. The periosteum is easily 
removed and the medullary portion is soft and traversed with trabeculse. 
The long bones may be soft and brittle in an early case, but in cases 
of long standing they become unusually firm and hard. In the bones 
of the skull similar periosteal changes occur which produce abnormal 
ossification and calcification. Many of the ligaments are imperfectly 

developed or abnormally 
stretched. The spleen is en- 
larged in about 10 per cent, of 
all cases. The liver and the 
spleen may be forced down- 
ward by thoracic deformities. 

Symptomatology. — The first 
evidences of rickets may escape 
attention unless the examiner 
considers the possibility after 
obtaining the history. Among 
the early signs are fretfulness, 
disturbed sleep and excessive 
perspiration about the head, 
in an anemic child. It is not 
easily comforted, and cries 
when moved as a result of 
muscle tenderness. In cases 
of longer standing, physical 
examination will show back- 
wardness in development. The 
infant may be unable to hold 
up its head, to sit up, or stand 
as a normal child at the same 
age. The muscles are. in gen- 
eral, soft and flabby, the ab- 
domen is distended and tym- 
panitic, and evidences of im- 
perfect digestion are found in 
the fetid stools and in the con- 
stipation alternating with an occasional diarrhea. In spite of this the 
appetite is generally good, more food being taken than is digested. 

In more advanced cases the spleen is palpable, and the anemia 
becomes more marked. The subjective symptoms above recorded 
become more intensified, and changes in the bony skeleton occur which 




Fig. 122. — Extreme rachitis, showing 
marked bony deformities. 



458 



DISEASES OF CHILDREN. 



can be felt on palpation. Among these the beading of the ribs at the 
costochondral junctions forming the so-called rachitic rosary is the 
most characteristic. In infants parchment-like areas in the occipital 
bones, known as craniotabes, is a finding which helps to establish 
the diagnosis. 

At the junction of the epiphysis and diathesis nodular bony en- 
largements are felt, particularly at the wrists, ankles, and knees. 
The forehead is marbled with enlarged veins and in shape is squared in 





Fig. 123. — Rachitis, mild form 
with bow-legs. 



Fig. 124. — Rachitis, showing 
pigeon-chest deformity. 



front and flattened on top. The fontanels are 
the line of the sutures being palpable. Bosses 
center of the parietal bones and near the base of 
At this stage there is generally an evening rise 
an accelerated pulse rate. The body weight may 
the increase may be very irregular. Dentition 
process. The first teeth are frequently delayed, 



late in closing, even 
may be felt in the 
the temporal bones, 
of temperature and 
remain stationary or 
is a very irregular 
sometimes erupting 



NUTRITIONAL DISORDERS. 



459 



only during the second year, and then with much discomfort. They 
easily decay, sometimes eroding almost to the gum. 

Nervous Phenomena often develop in the rachitic infant. Among 
these the most characteristic is laryngismus stridulus. This glottic 
spasm may occur several times a day and sometimes results in carpo- 
pedal spasms. In others nystagmus, tetany, or inspiratory crowing 
develops from the nervous instability. Convulsions are not uncom- 
mon and recur from apparently slight causes. 

Deformities occur later in the disease as a result of the softened 
condition of the bones and the relaxation of the ligaments. Be- 
sides the deformity of the 
head, the thorax shows 
marked changes. The ra- 
chitic rosary becomes more 
marked, due to a sinking in 
of the ribs in the axillary line 
and a flaring out of the ribs 
below. 

The thorax may be more 
or less funnel-shaped and ap- 
pear very narrow at the 
clavicles, due to the abnor- 
mal flaring below. The 
sternum may be drawn in- 
ward or pressed forward, 
causing the pigeon-breast de- 
formity. The anteroposte- 
rior diameter of the chest 
may be increased while the 
transverse diameter is lessened. Not infrequently a well-developed 
groove or sulcus is formed running from the ensiform on either side 
to the scapular line. This is known as Harrison's groove, and results 
from the pull of the diaphragm, intrathoracic pressure and the ab- 
dominal distention. These thoracic deformities necessarily affect the 
organs and structures within. The lungs are impeded in their action, 
favoring the production of bronchitis, pneumonia, and pulmonary 
collapse. The heart action and circulation may be impaired with a 
resulting cyanosis. Pneumonic affections are peculiarly resistant to 
treatment, and their chronicity may be responsible for lymph-node 
enlargements at the root of the lung. 

The hones of the extremities now show other changes besides the 
epiphyseal enlargements at the wrists and lower end of the tibia, 




Fig. 125. — Knock-knees in a rachitic child. 



460 DISEASES OF CHILDREN. 

which occur very early in the disease. The humerus may be curved 
outward while the legs are deformed from the weight put upon them 
in efforts to stand or walk. Bow-legs, knock-knees, and deformities of 
the foot are thus produced. The peculiar sitting posture of these 
children sometimes induces curvature of the femur. 

The spine, owing to the relaxed condition of the Hgaments, bony 
changes, and deficient muscular power, loses its normal curves, 
eventually becoming bowed from the cervical region to the pelvis. 
Lateral curvatures or scoliosis result from postural positions assumed 
while being carried in its mother's arms. The pelvis may suffer with 
the remainder of the skeleton, becoming flattened or shortened in its 
anteroposterior diameters. 

2'he blood shows no characteristic changes. Simple anemia is 
always present. The hemoglobin may be reduced to 40 or 50 per 
cent. A moderate leukocytosis is occasionally obtained. 

Diagnosis. — There is no difficulty in making the diagnosis in well 
advanced cases. In the early stages, pseudoparalysis, sweating of 
the head, anemia, irregular dentition, and a distended abdomen in a 
child exhibiting abnormal nervous symptoms are often sufficient to 
suggest the diagnosis. 

Infantile paralysis may be distinguished by the electrical reaction 
or by obtaining mobility in the prone position by irritating the 
plantar surface of the foot. 

In hydrocephalus there is a true enlargement, in place of an 
apparent enlargement, of the circumference of the head, with a bulging 
fontanel (see Fig. 145). Syphilitic affections are monoarticular, 
while many joints are simultaneously affected in rickets. 

In Pott's disease the spinal deformity is angular and rigid, causing 
pain when attempts at motion or pressure ai^e made. 

Course and Prognosis. — The disease itself, while chronic, has a 
tendency to recovery when changes are made in the dietary and 
surroundings of the patient. But even if a cure results, many of the 
bony deformities remain. While it is seldom a fatal disease it m- 
fluences the mortality in early life because of the lowered resistance 
which it engenders. These children more readily succumb to respira- 
tory, intestinal, and infectious diseases. Under suitable treatment 
the disease may be arrested after two or three months, and further 
bony changes prevented. Nervous symptoms, such as laryngismus 
stridulus, are very promptly controlled when the proper treatment 
is instituted. 

Treatment. Prophylactic. — The education of mothers and of 
school girls by settlement workers in matters pertaining to the feeding 



i 



XUTRITIOXAL DISORDERS. - 461 

and hygiene of infants will do much to reduce the number of cases. 
Frequent regulation and supervision of artificially-fed babies by their 
physicians would prevent overfeeding with too strong formulae which 
so often occurs among the more intelligent classes. Examination of 
the breast milk in children who are not sufficiently developing may 
show a marked deficiency in the proteins or fats. Milk of this 
character may cause the development of rickets. Mixed feeding 
and improvement in the secretion should be attempted by proper 
food. 

Dietetic Treatment. — Dietetic instruction for the mother, an out- 
door life, and cleanliness are the necessary requirements for a cure. 
The food in the case of an infant must contain a sufficient amount of 
proteins. If the feeding has been on condensed milk and high dilu- 
tion or the proprietary foods, properly modified cow's milk will in a 
short time produce a marked improvement. The modifications 
recommended for difficult cases of infant feeding should be studied 
in this relation, as the change must be so made that it will be com- 
patible with the defective assimilation which is usualty present. 

Older children should have a diet list especially prepared for 
them which may contain fresh raw milk, yolk of eggs, butter, legumin- 
ous gruels, and vegetables suitable to their age. 

Hygienic Treatment. — ^Provision should be made so that the 
child may live as much as possible in the open air. In bright sunny 
weather at least five hours a day should be spent out of doors. A 
roof or a room with a sunny exposure and with open windows may 
be utilized for this purpose. Daily baths to which a pound of sea 
salt is added are given, unless contraindicated by muscular tender- 
ness. Mild forms of massage, breathing exercises, and gymnastic 
treatment given in the second year of life are productive of good 
results. 

Medication.— With the exception of cod-liA'er oil or olive oil, 
which is of value in older children, drug treatment is of little avail. 
Iron and arsenic may be given for the anemia after progress has been 
made in proper food assimilation. If phosphorus is administered, 
the oil or the elixir may be used, although this drug and the lime 
salts have not proven of an}" benefit in our experience. 

Deformities of the long bones may be prevented b}- not allowing 
the child to assume wrong positions and not encouraging them to 
stand or walk until the softness of the bones is overcome. The 
rachitic spine is corrected by keeping the child in the horizontal posi- 
tion in bed or on a frame. Surgical measures to correct bow legs 
and knock knees are necessarv in the advanced cases. 



462 DISEASES OF CHILDREN. 

Congenital Rachitis. 

{Antenatal Rachitis.) 

Rarely we see infants born with well-marked evidences of rickets. 
The rachitic fetus develops the affection in its intrauterine existence, 
probably during the placental period of nutrition (see Fig. 26) in 
consequence of disease or starvation in the pregnant mother. The 
infant is born with changes in the bony skeleton which, although not 
well-marked, resemble those in a lesser degree found later in rachitic 
infants. Craniotabes, enlarged epiphyses, and beaded ribs may be 
seen and palpated. 

Scorbutus. 

{Infantile Scurvy; Barlow's Disease.) 

Scorbutus is a constitutional disease clue to a prolonged faulty 
diet and characterized by pain and swelling in the extremities, and 
hemorrhages into the skin and mucous membranes. 

Etiology. — Proprietary infant foods, the continued use of steril- 
ized and pasteurized milk, food almost exclusively of one kind, as 
condensed milk or cereals alone, are the factors which produce the 
necessary predisposition to intestinal putrefaction and toxemia, and 
which may result in scurvy after some weeks or months. Although 
it occurs in children under two years of age, the latter half of the first 
year shows the greatest number of cases. Malnutrition from food not 
adequate to maintain development is also a causative factor of impor- 
tance. The chemical changes brought about in the food by boiling or 
evaporation in dry heat for the purposes of preservation are essentially 
the underlying cause of the disease. The cases occur more frequently 
among the well-to-do than among the dispensary cases, as the latter 
cannot afford proprietary foods, and much sooner give a mixed diet. 

Pathology. — Subperiosteal hemorrhages occur in the long bones, 
especially in the tibia and femur. The epiphyses show similar changes, 
usually in proportion to the involvement of the periosteum of the 
shaft. In some cases the periosteum itself, close to the bone, is 
infiltrated and thickened. The ribs in marked cases show these 
changes especially on their margins. The spleen may be found en- 
larged and hemorrhages occur in the pericardium, pleura, liver, and into 
the muscles. 

Symptomatology. Mild Cases. — Attention is usually first at- 
tracted to the infant because it cries when handled. The tenderness 
is especially marked about the lower extremities. The child is ex- 



NUTRITIONAL DISORDERS, 463 

tremely fretful and usually anemic. It is not uncommon to obtain a 
history of some fancied injury which may be misleading. The infant 
will hold the limbs motionless, usually in a position of flexion, and 
cries or screams when any attempt to disturb them is made. In some 
cases only one extremity may at first be tender. No fever and no 
swelling may be present at this stage in the early or mild types. 
Such a train of symptoms when present in conjunction with a history 
of prolonged feeding wdth artificial foods which lack the essential 
quaHty of freshness should be suggestive and the therapeutic test 
applied. 

If swellings are noted over the epiphyses in one or both extremi- 
ties, with swelling and engorgement of the gums, the diagnosis is 
quite certain. 

Aggravated Cases. — In these unrecognized or neglected cases, 
hematuria may be the first symptom for which the child is brought to 
the physician, or it may have been treated for rheumatism because 
of the sw^elling and pain at the ankles. Careful examination will show 
spongy gums, bluish in color, which may bleed on pressure. If 
teeth are present the gums override them, and ulcerations may be seen. 
Anemia is a constant symptom. The appetite is lost, the child cries 
constantly when handled and blood may appear in the stools. In 
exceptional cases blood is effused into the joints and the epiphyses 
may separate. Ecchymotic areas appear under the skin especially 
over the swellings on the lower extremities, but may also appear over 
the ribs. Concomitant rachitic changes may also be noted due to 
the nutritional faults. About the orbit, conjunctival hemorrhages may 
be seen or even protrusion of the eye-ball. The face is usually swollen, 
or even edematous. Albumin and casts are sometimes found in the 
urine. 

A collective investigation by the American Pediatric Society 
gave the following symptoms in their order of frequency: Pain and 
tenderness of the extremities, sponginess or puffiness of the gums, 
disability, anemia, cutaneous hemorrhages, hemorrhage from the 
rectum and hematuria. 

Diagnosis. — Infantile scurvy is rarely mistaken by those who are 
accustomed to obtain a good history and who make a systematic 
examination. Traumatism, acute articular rheumatism, and osteo- 
myelitis are differentiated by the swelling, which is mainly over the 
shaft of the bone, the absence of temperature, swollen gums, ecchy- 
moses in the skin, pseudoparalysis, and blood in the urine and stools. 
A radiograph will in questionable cases complete the diagnosis. 

Course and Prognosis.— The prognosis is very good when the 



Iff 



464 DISEASES OF CHILDREN, 

disease is recognized in its early stages and prompt treatment insti- 
tuted. The development of rickets or extreme malnutrition may 
delay the cure in aggravated cases. 

The great majority, even the neglected cases, recover under 
antiscorbutic treatment. Beneficial results are noted after a few days, 
the mild types showing remarkable changes within a fortnight. 

Treatment. Prophylactic. — The disease can be prevented by 
the use of some orange juice and untreated cow's milk in the dietary. 
Overanxious mothers should be warned against repasteurization of 
their infant's milk supply. 

Dietetic Treatment. — The food should be abruptly changed; 
fresh raw milk, properly modified is allowed. Orange juice, one 
ounce daily in divided doses, and expressed beef juice about one ounce 
during the day, in addition, are readily taken. Older children should 
be given mashed potatoes and minced vegetables, such as carrots or 
spinach. The limbs are encased in cotton wool and supported on a 
pillow until the tenderness disappears. Unnecessary handling should 
be avoided. Removal to the outer air should be made with the in- 
fant in its crib or on a pillow. The anemia needs no drug treatment 
as it disappears under the dietetic management outlined above. 

Marasmus. 

{Infantile Atrophy; Athrepsia.) 

Marasmus is a very common functional disorder in infancy, 
characterized by extreme emaciation resulting from inability to 
assimilate food. 

Etiology. — This is still obscure. It is usually seen in the first 
year of life. The greatest number of cases appear in institutions and 
in dispensary practice. Undoubtedly food poor in quality and given 
in great quantities, coupled with unsanitary surroundings, have a 
distinct etiologic bearing on the development of marasmus. If the 
digestive secretions have not been sufficiently developed by proper 
food or if they have been overproduced for some time in efforts to 
digest abnormal food constituents, then the disorder may insidiously 
appear with symptoms of acid intoxication. 

It is rarely seen among breast-fed infants unless there is a marked 
perversion of the supply. 

Pathology. — The gross lesions found in even a well-marked case of 
marasmus are surprisingly few. Microscopically, nothing character- 
istic can be described. The body is devoid of adipose tissue. The 
muscles are soft, pale, and thin. The overlying skin is dry and 



NUTRITIONAL DISORDERS. 



465 



wrinkled. Hemorrhagic areas are frequently seen beneath the skin 
and sometimes in the mucosa of the gut. The lungs are frequently- 
involved, showing either hypostatic pneumonia, bronchopneumonia, 
or atelectatic areas. We have found these often in combination. 
The liver is somewhat enlarged and fatty. The spleen may be soft, 
but is not enlarged. The kidneys show degenerative changes or at 

least a cloudy swelling. The 
heart is small, with pale muscle 
fibers. The mucous membrane 
of the intestinal tract is ex- 
tremely thin and pale. The 
stomach is usually dilated, and 
its lining is covered with ropy 
mucus. The agminate and 
solitary follicles stand out more 
prominently and give the 
'^shaven beard" appearance. 
The villi are not easily found, 
or in some cases are entirely 
absent. The lymph nodes are 
enlarged. In some cases con- 
nective-tissue changes take 
place in the intestinal mucosa 
in isolated patches. 

Symptomatology. — The 
train of symptoms begins in- 
sidiously. The mother usually 
brings the infant because she 
has noted emaciation in spite 
of the fact that the food has 
been the same or even increased 
in amount. The loss of weight, 
if recorded, is found to be 
steady but constant. The 
muscles become soft and flabby. 
The skin is loose and wrinkled. The facial appearance changes, due 
to the loss of fat, with a wrinkled forehead and sunken cheeks. The 
fat pads over the buccinators in young infants remain, however, almost 
to the end. The abdomen and thighs show the emaciation quite 
early. The skin feels harsh and dry and has lost its elasticity. The 
muscle tone especially over the abdomen is lacking. The emaciation 
progressing further, gives an ''old man" expression to the face. This 
30 




Fig. 126. — Marasmus. 



466 DISEASES OF CHILDREN. 

outward wasting that takes place corresponds with changes in the 
heart muscle. The pulse becomes weak, and anemia of a simple kind 
is present. 

A striking feature is the insatiable appetite. The infants will 
take an enormous quantity of food and still cry as if unsatisfied. 
The stomach dilates and vomiting may occur. The abdomen is 
distended with gas, and the liver may be palpated well down in the 
abdomen. The stools vary considerably. As a rule, they are mixed 
in color, with a greenish-yellow cast predominating. They contain 
much unchanged food, and the bulk is decidedly increased. The 
odor is musty and foul and almost characteristic. Diarrhoea may 
follow after several days of constipated movements. Erythemata 
in the napkin region develop and persist. The temperature is rarely 
much above normal, although subnormal readings are not uncommon. 
The thirst in some cases is extreme; the infants have a red, dry, and 
glazed tongue. A finger or the hand is sucked continually, which 
the mother attributes to hunger. The cry is a low moan or whine, and 
is not repressed when attempts at comforting the baby are made. In 
fact, it often cries more when disturbed. As the disease progresses 
the emaciation becomes extreme; the child resembling a living skeleton. 
The fontanel and eye-balls are sunken. Excoriations and bed-sores 
develop easily. Stomatitis is not infrequent. Otitis may develop. 
The breathing becomes shallow and feeble. Pneumonia, usually of 
the hypostatic variety, or convulsions frequently bring on the fatal 
termination. 

If the disease is arrested, the improvement is noted first in the 
stationary weight and improved condition of the stools. Later slight 
gains are made, however, with frequent discouraging remissions. 
Finally the gain is steady, but slow. 

Course and Prognosis. — The course is long and tedious, and even 
when improvement begins months are needed to regain a normal 
appearance and development. Unless the conditions are eminently 
favorable, the prognosis is extremely poor, the infant usually dying 
of some intercurrent disease. 

Treatment. — Since the disorder is the result of defective assimi- 
lation, and artificial feeding being at best the introduction of a foreign 
food, a good wet nurse (see p. 127) should be secured whenever this 
is at all feasible. Maternal milk even for one or two months has been 
sufficient in our experience to turn the balance from inevitable disaster 
to beginning success. A change of surroundings, especially in the 
case of the poor infant, is the next consideration. A life in a country 
district with plenty of fresh air and sunshine is of the greatest im- 



XUTRITIOXAL DISORDERS. 467 

portance. These infants should not be placed or taken for treatment 
in hospitals or asylums. Treatment in homes,, preferably in the country, 
which are under the direct supervision of a physician, is much more 
satisfactory. The Speedwell Society, at Morristown, N. J., is a good 
example of the best method of dealing with these cases. If the child 
is being breast fed it may be found after examination that the char- 
acter of the secretion may be improved, and meanwhile mixed feedings 
can be tried. If in spite of this no gain in weight is made, a radical 
change of the milk must be made. 

If artificial feeding must be resorted to, the problem is a very 
difficult one and will demand a knowledge of the principles of infant 
feeding, so that the food may be adapted to the needs of the case at 
hand. A detailed history of the previous feeding is essential, and it 
is not unusual to find that these cases have gone through the gamut 
of almost every conceivable food in an effort to find something that 
will agree with the baby. 

Begin the dietetic management by clearing out the intestinal 
tract with calomel or castor oil. If there has been vomiting, lavage 
is indicated once a day for two or three days. A daily irrigation of the 
bowels with saline solution for the first week is rarely amiss (see 
pages 88 and 90). 

Feedings should be small in quantity, and contain at first protein 
and fat slightly above the caloric value necessary to maintain life. 
The gruel diluent should be converted by a diastatic ferment, and, if 
necessary, the milk may be peptonized. It is a good rule not to pre- 
scribe, no matter what the age, greater percentages than 2 per cent, 
fat, 6 per cent, sugar, and 1 per cent. jDrotein. Xot infrequently the 
marasmic infant does not do well on an}^ ordinary milk modifications, 
because the infant has been neglected too long or fed upon foods 
which do not react to the rennin in the stomach. Legume gruels, 
one to two ounces of the flour to the quart, with the addition of one 
teaspoonful of pineapple juice to each four ounces of feeding is given 
until the stools change in character. Whey alternating with the le- 
gume gruel (see section on Infant Feeding) is then cautiously tried, 
and as soon as it is tolerated, the yolk of one egg rubbed up with a 
quai'ter of a teaspoonful of sugar is fed daily from a spoon. Cream 
may now be added gradually to the whey and this mixture may en- 
tirely replace the gruel. If gain in weight is made and development 
progresses, milk and gruel mixtures containing 1.5 per cent, of 
protein with the addition of sodium citrate, one grain to the 
ounce, may be given so that the rennin action may be controlled. 
As the digestive secretions improve the infant is able to adapt itself 



468 DISEASES OF CHILDREN. 

better to the form of food prescribed and in this resembles again the 
normal baby. 

Progress will only be made by careful attention to every detail 
and a study of the stools before making any advances in the strength 
of the food. The fats may be kept low with advantage; the protein 
being raised if the dejecta appear to warrant it until a satisfactory 
gain in weight is being made. 

Medication is only indicated to support the strength until the 
dietetic measures are sufficiently advanced to support life. For this 
purpose strychnin is valuable. Alcohol in any form, if given for any 
length of time, does more harm than good. Bismuth is occasionally 
necessary to allay intestinal irritation. 

Baths are decidedly helpful adjuncts in the management. Brine 
baths are especially valuable. They are given warm and followed 
by a brisk alcohol rub daily. Asthenic cases may at first need sub- 
cuticular injections of normal saline solution, or the use of sea 
water as advocated by Simon may be tried. 

Diabetes Mellitus. 

This is a condition of persistent glycosuria rarely seen in child- 
hood, and differing from the same affection in adult life by rapid wasting 
and a speedy fatal ending. 

Etiology. — While rarely, if ever, seen in young infants, the disease 
may occur in children, oftenest between the ages of five and ten years. 
Heredity is supposed to act as a predisposing cause, and a diet con- 
taining excessive amounts of starch and sugar may have a causative 
influence. The real cause and pathology of diabetes mellitus are as 
obscure and uncertain in the child as in the adult. 

Symptomatology. — Among the earliest symptoms noted is an ex- 
cessive thirst. A child who has been previously well-nourished, besides 
drinking great quantities of water, is seen to be listless or irritable, 
easily tired and with a large and capricious appetite. Failure of nutri- 
tion and strength soon follow, and in a short time, possibly within a 
few weeks, the wasting becomes very appreciable. The urine is passed 
frequently and in large amounts. Several quarts may be voided in the 
twenty-four hours. The specific gravity is high, as in older subjects, 
and large quantities of sugar and occasionally diacetic acid and acetone 
may be found. Nocturnal incontinence is usually present. Irritation 
of the genital organs is sometimes caused by the passage of the sugar. 
The skin and mucous membranes are apt to be dry, and the former 
may show patches of eczema and occasionally boils. Itching of the 



XUTRITIOXAL DISORDERS. 469 

skin may be marked and annoying. The wasting and loss of strength 
proceed with great rapidity and death is apt to ensue from exhaustion. 
In some cases the fatal ending is due to an intercurrent pneumonia and 
in others to diabetic coma. The disease generally runs its course 
within a few months and usually under six months. The younger 
the child the more rapid is apt to be the course of the disease. 

Prognosis. — We have never seen a case recover in a young child. 
In any given case of glycosuria, the only hope is that the condition 
is temporary and due to an excessive ingestion of starches and sugars, 
the so-called alimentary glycosuria. There will then be an absence 
of wasting and the other symptoms previously noted. 

Treatment. — The diet must consist, as far as possible, of milk, 
meats, fats, eggs, and green vegetables. Von Xoorden recommends 
oatmeal that has been long and thoroughly cooked, which then ap- 
pears to be well-borne by diabetics in spite of its starch, and he thinks 
it has a curative tendency. The weakness may be combated with 
alcohol and strychnin. Small doses of morphin and codein may also 
be tried. 



SECTION XI, 
DISEASES OF TPIE UROPOIETIC SYSTEM. 



CHAPTER XXXIII. 
DISORDERS OF THE URINE AND KIDNEYS. 

The Urine in Infancy. 

The somewhat vague and conflicting reports concerning the early 
secretion of urine are due to the difficulty of collecting it. The follow- 
ing methods have heretofore been relied on: Placing a small sponge 
or piece of absorbent cotton over the parts, which is intended to be 
saturated with the urine, and then squeezed out; in females, fitting a 
cup or wide-mouthed bottle or pus basin under the vulva to be held in 
place by the diaper; in males, placing a bottle or condom over the penis 
and holding it in position by straps of adhesive plaster. When these 
methods fail, as often happens, the only resort left has been the cathe- 
ter, a soft-rubber catheter, about 6 size, being best to employ. In 
females, where the greatest difficulty is usually encountered, the 
employment of a catheter is not always easy, and several preliminary 
passages into the vagina often occur in the hands of the inexperienced. 
To obviate these difficulties and to make easy and safe the routine 
collection of the infant's urine for examination, a special urinal has 
been devised. It consists of an oval opening ending in a funnel that 
fits into the collecting vessel. For 
efficiency of application, two sizes 
have been found necessary. No. 1.' 
(Small size). For infants under 
one year. No. 2. (Large size). 

For infants over one year. 

T^T , , 1 . 1 Fig. 127. — Chapin's infant urinal. 

Place the large openmg around '■ 

the vulva in the female and over the parts in the male with the 

funnel pointed downward. Put tapes through the openings in the 

arms and fix by tying around the abdomen and both groins. To 

fix more firmly in place, put strips of plaster over the arms. Place 

the end of the funnel in the collecting bottle which is kept in place 

by the diaper. If the infant is very restless, put a cork in the end of 

the funnel and 'dispense with the bottle. 

It was hoped that this apparatus would enable one to collect the 

full amount passed in twenty-four hours, but this has not proven 

470 




DISORDERS OF THE URINE AXD KIDXEYS. 



471 



feasible without constant watching, as the movements of the baby 
make a small leakage unavoidable. 

Character of the Urine. 

That the Iddneys functionate before birth is shown by the blad- 
der usually containing urine just after birth, and from traces of this 
excretion in the liquor amnii. The kidnej^s at this time are of rela- 
tively large size and more distinctly lobulated than in later life. 
There is a great discrepancy among the various writers as to the 
amount of urine passed during the early da3's of life. All agree that 
the infant passes a relatively greater amount of urine than the adult. 
Parrot and Robin state that the new-born passes four or five times 




Fig. 128. — Cliapin's infant urinal applied, 
m-ore urine, per kilogram of its weight, than the fully-grown sub- 
ject. They also found that the urine at this time has always about 
the same composition, whether passed in the morning or evening. 
The quantit}^ and product of each urination varies but little as the in- 
fant has no urine of sleep, digestion, etc., since he takes an identical 
food and at nearly the same intervals of time. These authors found 
that the morning voiding varied from 10 to 30 c.c. Small amounts 
may be voided every hour through the day and several times at night. 
There seems to be a concensus of opinion among various observers 
that during the first few days the young infant excretes about from 
one to three ounces of urine, and after this the quantity rapidly in- 
creases. At the end of the first week there may be from three to 



472 DISEASES OF CHILDREN. 

twelve ounces; at six months, twelve to sixteen ounces; at one and two 
years, from sixteen to twenty ounces; from two to five years, twenty 
to thirty ounces, and after that, approximating the adult. It must be 
confessed that these figures are general and tentative and seem to be 
a fair estimate after considering many conflicting figures of the various 
writers. The amount will vary in proportion to the quantity of fluid 
given as well as the action of the bowels and skin. 

The specific gravity is low, rarely rising above 1010 during the 
first six months. A few days after birth and until the end of the 
first month the specific gravity is very low, only averaging from 1003 
to 1004, as urea and inorganic salts are not found in large quantity at 
this time. It then increases in density, but it is not apt to rise much 
above 1010 until after the tenth year, when it may reach as high 
as 1020. 

The first urine is clear colored, although it is sometimes reddish 
from an excess of uric acid and urates. In the latter case it may be 
scanty and passed by drops which discolor the diaper. The uric acid 
crystals may even form concretions in the pelvis of the kidney. In- 
fants seem to form uric acid with great facility, but the proportion 
of uric acid to urea diminishes later, though comparatively large all 
through childhood. In proportion to the body weight there is rela- 
tively less urea excreted by the infant than by the child, although 
the latter excretes more than the adult. This may be accounted for 
by the active metabolism occurring in early life. 

The reaction is usually neutral or faintly acid. In the cases men- 
tioned where large amounts of uric acid are formed and eliminated dur- 
ing the few days after birth, the reaction will be markedly acid. The 
reaction may be at times slightly alkaline without being considered 
abnormal. 

The question as to the presence of what may be considered patho- 
logical ingredients at this time and their significance is interesting, but 
one upon which various writers are not in accord; some state that traces 
of albumin and hyalin casts are occasionally found during the first 
days of life and with little significance. According to Martin Ruge, 
both hyalin and granular casts may be found in the urine of the 
newly-born. Parrot and Robin, on the contrary, never found albu- 
min in the urine of healthy new-born infants, nor mucus or hyalin 
cylinders as in normal urine of the adult. Slight glycosuria has occa- 
sionally been reported during the early months, especially when sugar 
has been too freely given in the food. All through infancy traces of 
indican will be found in connection with gastrointestinal irritation. 

During the early years of life slight renal hyperemia appears to 



DISORDERS OF THE URIXE AND KIDXEYS. 473 

be very easily induced and to be coincident to almost an}^ marked 
bodily disturbance. 

The rapid metabolism occurring at this time of life and the 
vulnerability of the kidneys will occur to everyone. A careful 
examination of the urine in various conditions is presented in the 
following series of cases from the babies' wards of the New York 
Post-Graduate Hospital. The first series includes eighty-six cases 
in which some disturbance of the gastrointestinal tract was present. 
Xo attempt was made to classify these cases, and they include simple 
indigestion, fermentative diarrheas, intestinal inflammation and ma- 
rasmus. In a large number the condition was not severe, and such 
cases were purposely included in the list. Albumin was present in 
seventy-five cases in this series of eight-six. Its presence was noted 
as follows: trace, twenty-nine; faint trace, thirty-one; heavy trace, 
fifteen. Casts were present in thirty-seven cases, noted as hyalin, 
granular, epithelial, and mucous. There were sixteen deaths in the 
series, and of these fourteen had albumin present and ten both al- 
bumin and casts. In thirty-two cases an examination for indican 
was made and found present in twenty-two of the cases. The 
amount was estimated as follows: trace, four; faint trace, one; 
heavy trace, seventeen. 

A series of fifty-seven cases of pulmonary diseases, such as severe 
bronchitis, pleurisy, and pneumonia, gave the following results: 
forty-nine had albumin in the urine, thus noted; trace, thirteen; faint 
trace, thirty; heavy trace, six. Thirty-two cases had casts present, 
either hyalin, granular, epithelial, or mucous. Of the seventeen 
deaths in this series, fifteen had albumin present and ten both albumin 
and casts. An examination for indican in twenty-three specimens 
showed its presence in sixteen cases. Trace, two; faint trace, two; 
heavy trace, twelve. 

In forty-five cases of general illness, other than pulmonary and 
gastrointestinal, albumin was present in thrty-one cases. Trace, nine; 
faint trace, eleven; heavy trace, eleven. 

In eleven cases of cerebrospinal meningitis, nine showed heavy 
traces of albumin and casts. 

In a number of cases of cerebrospinal meningitis, with coma, a 
special effort was made to collect the twenty-four hours' amount. A 
baby of nineteen months passed 18 ounces, one of two years passed 
16 ounces, one of three years passed 16 ounces, and one of four years 
passed 20 ounces. • All of these specimens had traces of albumin and 
casts, and the urea varied from 1.7 to 2.7 per cent. 

It is evident that emy disturbance of the bodih' functions during 



474 DISEASES OF CHILDREN. 

infancy will often be accompanied by the presence of albumin and 
casts in the urine. What significance does this condition present ? 
Can actual renal disease be considered to exist when traces of albumin 
and a few casts are found, or is there simply an irritation of the renal 
tubules accompanying a slight congestion and having no special 
significance ? To the writer's mind a study of the cases here reported 
favor the latter view. Koplik, in a study of twenty-five consecutive 
cases of gastroenteritis, found that all but four showed a more or less 
severe involvement of the kidney. In all of these cases there was 
albuminuria, and the majority of them showed the presence of casts. 
This author further says that in view of the peculiar physical signs, 
and the rapid improvement of an almost complete suppression, without 
leaving behind any appreciable lesion of the kidney as evidenced by 
albumin or casts in the urine, it is seen we are not dealing with a 
nephritis in the ordinary, but in a special sense. As in these cases there 
is usually a great loss of fluid from the system, the toxins circulating 
in the different organs are thus placed in contact with the delicate cell 
structures in concentrated form. As soon as the water taken* from 
the system is partially supplied, these poisons are washed from the 
organs, and the latter have an opportunity to resume their functions 
and are restored to normal. The moral is not to employ irritating 
antiseptics in the treatment of intestinal diseases and to give a full 
and free supply of water. 

It would seem that we are justified in concluding that the urine 
of infants may contain traces of albumin and even casts without any 
very grave results. Even w^hen actual congestion or parenchymatous 
inflammation exists for quite a long time, it may be remembered that 
in early age the kidney possesses a wide power of regeneration. 

The exceedingly fine tests now often employed in examining 
for albumin must be noted as one explanation of its frequent discovery. 
As small amounts of nucleoproteid are always present in urine, prob- 
ably derived from the disintegration of the epithelial cells from some 
part of the urinary tract, such as the ureter or bladder, fine traces 
of albumin may come from such a source. 

Formation of the Kidney. 

First are noted two minute oval structures appearing about the 
seventh week of fetal life. As these masses develop into the kidneys, 
they assume a marked lobulated form, and this structural pecuharity 
persists until shortly after birth when this distinctively lobulated 
structure disappears. The kidneys are relatively larger in the new- 



DISORDERS OF THE URINE AND KIDNEYS. 475 

born than in older subjects and are placed a little lower down in the 
abdomen. The suprarenal capsules nearly cover the kidneys at first 
and are relativel}" large all through childhood. Malformations have 
been rarely noted, such as a fusion of both kidneys into an irregular, 
horseshoe mass. Congenital cystic kidneys have been occasionally 
reported due to stenosis of the pelvis, ureters, bladder or urethra, fol- 
lowed by a dilatation of the capsules of the Malpighian bodies and 
of the tubules. As a result, the kidneys may be greatly enlarged, con- 
sisting of a mass of cysts. A feAv cases of single kidney, supernumer- 
ary ureters, and other rare anomalies have been reported in the 
literature of the subject. 

Anuria. 

This term applies to a cessation of the urinary secretion. In the 
newly-born note should always be taken of the first passage of urine. 
Its non-appearance may be due to some congenital malformation in 
any part of the urinary tract. Delay in voiding at this time is most 
commonty caused by uric acid infarction in the kidneys. The highl}^ 
acid urine may then pass in drops which dry upon the diaper and the 
nurse will report that no' urine is being passed. Sometimes a reddish- 
brown, brick-clust discoloration is left upon the diaper, and the in- 
experienced will think that the infant has been passing bloody urine. 
There may be anuria for twenty-four hours from this cause without 
the infant showing any constitutional disturbance. Examination 
will usually show" that the bladder Is empty. There are occasionally 
cases in young infants where no urine is passed from twelve to twenty- 
four hours, as far as can be seen, and, as long as there is no apparent 
bodily disturbance, it need not cause undue alarm. In older children 
anuria may be caused by various drugs, such as phosphorus or arsenic; 
by nervous disturbances, as from fright, hysteria, etc. ; there may like- 
wise be complete suppression in the course of acute nephritis. 

Treatment. — Before deciding that a case is one of true anuria, 
the bladder must be examined to be sure that we are not dealing with 
ordinary retention. To be absolutely sure of this, it may sometimes 
be necessary to pass a catheter. A soft-rubber catheter, about 6 
size, is best employed in the young infant. When there' is actually 
a stoppage of the urinary excretion, the kidneys may be stimulated 
into action by slowly injecting into the bowel large quantities of warm 
normal salt solution. Hot fomentations over the kidneys may like- 
wise be tried. The best diuretic is pure water given frequently and 
freely. When the urine is scanty and very acid, the young infant 



476 DISEASES OF CHILDREN. 

may be given from one to three grains of citrate or acetate of potash 
every two or three hours in a tablespoonful of water. One or two 
drops of sweet spirits of niter may be combined with the alkali or given 
alone to favor diuretic action. 



Polyuria. 

A temporary increase in the amount of urine excreted may be 
caused by the administration of large quantities of fluid, such as milk 
or water, by irritation of the base of the brain, by hysteria, by the 
cirrhotic form of nephritis, or by diuretics. As a rule, the condition 
is due rather to functional than organic disturbance. 

Diabetes Insipidus. 

When polyuria assumes a chronic form and there is a daily ex- 
cretion of large quantities of pale-colored urine having a very low 
specific gravity, the condition is known as diabetes insipidus. The 
real pathology of this disease is not understood, but the prevailing 
opinion is that it owes its inception to some sort of neurosis. The 
causes are obscure, but cases have been reported where heredity 
seemed to be a factor and others seem to be coincident to injuries of 
the brain induced by falls or blows, and to the various forms of menin- 
gitis. The disease begins early in life, the majority of the cases reported 
being under ten years. An evacuation of very large quantities of 
watery-looking urine is characteristic of the disease, even as much as 
ten quarts may be passed daily. The specific gravity is very low, 
varying from 1001 to 1005, and the urine contains neither albumin 
nor grape sugar. Urination is frequent and may reach a condition of 
incontinence. There is great thirst and the patients drink very large 
amounts of water to make up for the constant loss. The loss of fluid 
sometimes induces a condition of dryness of the skin and mucous 
membranes with diminished glandular secretion. Palpitation of the 
heart, neuralgia, and headache may occasionally be present, and vaso- 
motor disturbances, such as flushing of the face. When the disease 
has lasted a long time the general nutrition is apt to suffer and the 
bodily resistance is lowered. In many cases, however, the appetite 
is good and the general health does not seem to be affected. While 
occasionally a case may recover spontaneously, the disease is usually 
chronic, lasting many years, and death finally ensues from some inter- 
current disease. The diagnosis is made by noting the continual 
passing of very large quantities of pale urine with low specific gravity, 



DISORDERS OF THE URINE AND KIDNEYS. 477 

but without grape sugar, albumin or casts of any kind. Excessive 
thirst is likewise always present. 

Treatment. — The best results will be attained by hygienic meas- 
ures. The diet must be carefully regulated, only easily digested articles 
being allowed. The ingestion of fluids may be moderately restricted. 
Warm clothing with a free, out-of-door life and a pleasurable amount of 
exercise are valuable hygienic agencies. Drugs have little effect upon 
the course of the disease. The following have been recommended: 
atropin or belladonna, antipyrin, the various bromids, ergot, and 
arsenic. 

Renal Calculi. 

Uric acid infarctions often are found in newly-born infants. 
They consist usually of uric acid or urates deposited in the straight 
tubes. The calices and pelvis of the kidneys may at the same time 
contain small masses of uric acid or the urates of ammonium and 
sodium. These concretions should disappear by the end of the first 
or second week. They are caused by the abundant excretion of uric 
acid during the first days with an insufficient supply of water to hold 
the salts in solution. As noted in another section, the urine may be 
passed in drops leaving a dark red stain upon the napkin, or there 
may even be temporary anuria in this condition. A true renal lesion 
is not apt to follow. A free administration of water will generally 
induce a solution and washing out of these deposits. Small calculi 
sometimes persist in the pelvis of the kidney or they may be formed 
later by the deposition of uric acid or the urates. When the calculi 
are not dissolved they may be washed down into the ureter and pro- 
duce the symptoms of true renal cohc. There is then acute pain in 
the region of the kidney radiating downward, with possibly even 
retraction of the testicle on the affected side. Small amounts of urine 
are frequently passed which may be tinged with blood. In older 
children there may be vomiting and marked evidences of prostration. 
When the calculi reach the bladder the pain quickly ceases. Pro- 
longed acts of screaming on the part of infants, otherwise unaccounted 
for, are doubtless often due to the passage of small crystals of uric 
acid through the ureter. The only way to be positive, however, is to 
examine the urine when voided for the presence of these crystals. 
Occasionally, but rarely, a good-sized calculus may become impacted 
in the urethra. Examination may be made for this condition in 
cases of anuria, and evidences of local discomfort will be a guide for 
the search. The irritation of pelvic calculi may sometimes induce a 



478 DISEASES OF CHILDREN. 

mild form of pyelitis. Where a large calculus becomes firmly 
wedged in the ureter it may produce a complete stoppage which will 
eventuate in hydronephrosis. 

Treatment. — Young infants should be given water as a routine 
measure, from a teaspoonful at first to half an ounce later, several 
times daily, in order to keep the uric acid and urates in solution and 
flush out the kidneys and urinary tract. When the urine becomes 
scanty and high-colored the water may be given even oftener, and 
one or two grains of citrate or acetate of potash added every three 
hours will form a good alkaline water. Older children must have 
their diet carefully regulated and fluids freely given. The indications 
for surgical interference are the same as in adults. 



Hematuria. 

The red blood-corpuscles may be present in the urine either from 
certain general disturbances of the body or from local causes in the 
genitourinary tract. As an example of the first may be cited infec- 
tious diseases, such as variola, scarlet fever, or severe paludism; various 
blood diseases of obscure origin, such as hemophilia and purpura; 
scorbutus and large doses of irritating drugs, such as chlorate of 
potassium. Among local causes may be mentioned acute nephritis, 
new growths in the kidney or bladder, and calculi in the kidney, ureter, 
bladder, or urethra. Some help may be had in discovering the source 
of the bleeding by noting the condition of the urine as passed. If the 
blood is thoroughly mixed with the urine at this time, the source is 
apt to be in the kidney. Where the bladder is the seat of the hemor- 
rhage, the blood is usually passed at the end of urination, while if the 
urethra is affected, the first urine passed contains the blood. Small 
amounts of blood in urine may give it a slightly reddish or smoky 
appearance, while large quantities may appear as clots. In any 
uncertain case the microscope must be depended on for the diagnosis. 

Treatment. — This must be directed to the cause, but small doses 
of the fluid extract of ergot may be frequently given if the bleeding 
continues. 

Hemoglobinuria. 

Hemoglobin may be present in the urine with very few or no 
blood-cells. It is occasionally seen in the same infectious diseases 
that may produce hematuria; also from irritating drugs that are 
eliminated by the urinary organs as carbolic acid and chlorate of 



DISORDERS OF THE URINE AXD KIDXEYS. 479 

potassium. It is also rarely seen in an epidemic form, occmTing in 
the newly-born, known as Winckel's disease. The diagnosis is 
made by the microscope which shows the blood pigment granules, 
but not the reel cells themselves. 

Functional Albuminuria. 

{Cyclic or Physiologic Albuminuria.) 

An occasional albuminuria, without casts or other evidences of 
kidney disease, may be noted in children. It is more ajDt to occur 
shortly before or during adolescence. The cyclic form is apt to exhibit 
itself in the urine passed during the day, while the patient is on his 
feet, but disappears during the night and early morning. This is 
explained by posture, as there is no albumin present when the patient 
is lying down, but appears after the erect posture is maintained. Cold 
bathing, overexercise, too large injestion of protein food, and various 
forms of indigestion and malassimilation have all been advanced to 
explain transient albuminuria. There are usually no symptoms, and 
the patient may even show all the signs of apparently perfect heath. 
There is frequently the same uncertainty and obscurity in this con- 
dition in childhood as in later life. The cases should be kept under 
observation and if albumin persists very long, even in small amounts, 
there is probably some lesion in the kidneys. The condition of the 
heart and the tension of the pulse must be watched, as beginning 
hypertrophy and constant high tension point to kidney trouble. While 
being observed, the diet should be carefully regulated, overfatigue 
prevented, and attention given to general hygiene rather than to 
measures directed to the kidneys. 

Indicanuria. 

Indican in minute traces may be found in normal urine, but the 
condition may be considered abnormal when a marked reaction is 
given to the test. It is usually seen in the various forms of intestinal 
indigestion and fermentation. The putrefaction of proteins under 
the action of various bacteria results in a substance known as indol 
from which the indican is derived. The condition is sometimes 
also noted in tuberculosis, empyema and various diseases accompanied 
by suppuration. The treatment is dietetic and directed against the 
various forms of intestinal disturbance that are accompanied by 
undue food decomposition within the intestine. The color scheme and 
test for indican are given in the section on Special Tests (p. 57). 



480 DISEASES OF CHILDREN. 

Acetonuria and Diacetonuria. 

Minute traces of acetone and diacetic acid may be found in 
normal urine. They may be increased in fevers and in any condition 
accompanied by undue protein decomposition. They have been 
found in cases of diabetes followed by coma. 

Congestion of the Kidney. 

As the kidneys functionate very actively in early life, various 
grades of hyperemia may be easily induced. The various infectious 
conditions, marked digestive disturbances, high fevers from any cause, 
irritating drugs, and exposure to cold may be accompanied by traces 
of albumin and tube casts in the urine. This does not necessarily 
mean that there is the beginning of an acute nephritis, as the 
condition may pass away with the subsidence of the cause of the irri- 
tation. If the latter persists too long, however, actual nephritis 
may ensue. In a previous section, evidence was shown that almost 
any marked bodily disturbance, especially in infancy, will often be 
accompanied by the presence of albumin and casts in the urine. This 
may be simply an evidence of irritation of the tubules accompany- 
ing a slight congestion. The urine may be scanty, but if there is 
nothing beyond congestion, even if extreme and followed by almost 
complete suppression, there will be a rapid improvement without leav- 
ing behind any appreciable lesion of the kidney. A congested kidney 
is apt to be somewhat enlarged as there is more blood in the vessels 
than normal, and if the condition has lasted for several days the cortex 
may be very red and have the gross appearance of cloudy swelling. 

The treatment includes keeping the bowels free and giving 
plenty of pure water. The latter is especially important in condi- 
tions accompanied by a great loss of fluid when the toxins circulating 
in the different organs in concentrated form irritate the delicate cell 
structures, of the kidney as of the other vital organs, and hence need 
dilution and washing out from the system. The skin must be kept 
warm and moist and hot fomentations over the kidneys sometimes 
appear to do good. A milk diet is best. 

Chronic Congestion. 

(Passive Hyperemia of the Kidney.) 

Chronic lesions of the heart or lungs or any pressure effect that 
interferes with the general circulation, and thus with the kidney 
circulation, may result in chronic congestion. It occurs principally 



DISORDERS OF THE URINE AND KIDNEYS. 481 

in older children. A long-continued impeded circulation through the 
kidney will be followed by enlargement of the organ caused by a dis- 
tention of the vessels with blood. On section, a dark-red color is 
noted. The urine is passed in small amounts, with high specific 
gravity, and usually showing albumin and tube casts. 

The treatment must be directed to the skin and bowels, with the 
use of various diuretics, all of which are noted in our consideration 
of the treatment of nephritis. The principal treatment must naturally 
be aimed at the original condition that results in keeping up the con- 
gestion. 

Nephritis. 

In attempting to classify the various forms of nephritis from the 
standpoint of morbid anatomy, the student at the bedside will be 
much confused. It is often impossible to diagnosticate the anatomical 
varieties of nephritis by either a study of the clinical symptoms or of 
the urine. The physician frequently cannot tell whether he is dealing 
with acute congestion, acute degeneration, or acute glomerulonephritis 
of a mild type. From the standpoint of treatment, it is not very 
important to attempt to sharply differentiate these various disturb- 
ances. Nephritis will be here considered only as acute or chronic, 
although the synonyms will show the lesions that may preponderate 
in each condition as far as the epithelial, interstitial or vascular tissues 
of the kidney are concerned. 

Acute Nephritis. 

(Acute Parenchymatous Nephritis; Acute Exudative Nephritis; 
Acute Desquamative Nephritis; Acute Tubular Nephritis; Acute 
Glomerulonephritis; Acute Diffuse Nephritis; Acute BrighVs 
Disease.) 

Definition. — An acute inflammation involving any or all (diffuse) 
of the histological structures of the kidney. 

Etiology. — Acute nephritis commonly occurs as a secondary con- 
dition in the course of the specific infectious diseases. Scarlet fever 
and diphtheria most frequently induce nephritis, but variola, varicella, 
measles, meningitis, typhoid fever, and influenza may also be noted 
as not infrequent causes. Any severe disease, such as pneumonia or 
acute enteritis, may irritate the kidney to the point of inflammation 
in striving to ehminate noxious products. Thus the colon bacillus 
may be the irritating agent. Cases that are considered primary are 

31 



482 DISEASES OF CHILDREN. 

doubtless usually due to some infection that is obscure as to its point 
of entrance. The kidney lesions may be started by the toxins gen- 
erated by infectious bacteria or may be caused by the direct action 
of the organisms themselves, in which case the disease assumes a severe 
type. Exposure to cold and wet may cause nephritis, possibly by 
checking the action of the skin and thereby throwing extra work 
upon the kidneys, or possibly by lowering the vitality so that various 
bacteria will grow sufficiently to infect the body, as in tonsillitis. The 
continued ingestion of drugs irritating to the kidney, especially 
chlorate of. posash or the carbolic acid series, may induce nephritis. 

Pathology. — The kidneys are usually congested, soft and some- 
what enlarged, the cortex being swollen and presenting the appear- 
ance of cloudy swelling. The pyramids generally appear congested. 
In other cases the kidney shows little apparent change to the naked 
eye. Under the microscope, changes may be noted in the epithelial, 
interstitial or vascular tissues. The various names have been given to 
the nephritis according to the tissue that is preponderatingly affected 
by the inflammation. When the glomerular lesions are most marked, 
it may be called glomerulonephritis; if the glandular, epithelial cells 
in the tubules are mostly affected, we have parenchymatous nephritis; 
if the stroma is principally affected, it is named interstitial nephritis. 
When all the anatomical structures of the kidney are markedly in- 
volved, it is called diffuse nephritis. The renal cells of the tubules, 
as seen under the microscope, show cloudy swelling, degeneration and 
sometimes desquamation. The tubules may be filled with casts. 
In the glomerular type, the cells covering the capillary tufts undergo 
swelling and proliferation. The cells making up the capsules of the 
Malpighian bodies may likewise undergo proliferation. There may be 
an infiltration of the stroma, with leukocytes and plasma cells and a 
production of new connective-tissue cells. The blood-vessels of the 
affected part are engorged, and there may be a proliferation of the 
cells of the capillaries. 

Symptomatology. — In early life, nephritis most frequently occurs 
as a secondary condition in the infectious diseases, especially in 
scarlet fever. It may come during the height of the primary disease 
or when the latter is subsiding. In scarlet fever it is more apt to 
ensue during the period of desquamation in the third and fourth week. 
The urine becomes scanty with a reddish-brown, smoky discoloration 
from the presence of red blood-cells or hemoglobin. Albuminuria is 
present, usually in marked degree; it may be so extreme as to change 
the urine into a solid on boiling. The urea is only partly excreted by 
the crippled kidneys, and hence accumulates in the blood. The amount 



DISORDERS OF THE URINE AND KIDNEYS. 



483 



of urea daily found in the urine is thus below normal. The specific 
gravity may be diminished, but when the urine is loaded with albumin 
it usually is as high or higher than in normal urine. Epithelial, 
granular and 'hyalin casts are usually found in abundance. Renal 
epithehal cells, red blood-corpuscles and leukocytes are also present. 
The temperature in nephritis is not apt to be very high, perhaps 
averaging from 101° to 102° F.; if it goes much higher— such as 104° 

to 105° F. — it shows a severe 
type of the disease. The ner- 
vous sjaiiptoms vary with the 
severity of the attack. In mild 
cases there may be only apathy 
or restlessness and slight head- 
ache; in severer cases there is 
worse headache, dimness of sight, 
stupor, coma, or convulsions. 
A high tension pulse usually 
precedes the symptoms of ure- 
mia. The graver nervous symp- 
toms usually come in connection 
with scanty or suppressed urine 
and they disappear as the secre- 
tion becomes more abundant, 
with a lessening of the amount 
of blood, albumin and casts, and 
a freer elimination of urea. The 
cerebral symptoms may be 
caused by a general edema of 
the brain or by a compression of 
Fig. 129.-Puffiness of the face and edema of ^j^^^ ^^ / ^^ effusion of 

the extremities m a case ot acute nephritis. . 

serum withm the ventricles. 

The principal gastroenteric symptom is vomiting, without much or any 
nausea, and occasionally diarrhea is seen in the uremic state. More or 
less dropsy, due to a transudation of serum caused by the altered con- 
dition of the blood, is one of the commonest symptoms of the disease. 
It usually begins as a slight anasarca of the feet and ankles from 
whence it may extend up the legs to the scrotum and finally to the 
trunk. An effusion of serum in and around the internal organs with 
grave results may take place in the following usual order of frequency 
— edema of the lungs, effusion into the pleural and peritoneal cavities, 
into the pericardial sac, into the brain, and finally into the loose con- 
nective tissue of the larynx producing that alarming and fatal cou' 




484 DISEASES OF CHILDREN. 

dition, edema of the glottis. The anasarca is apt to precede these 
internal effusions but this is not invariably the case. It is evident 
that dropsy as a symptom may induce little or no discomfort to the 
patient or seriously threaten his life according to the part of the body 
affected. The types of nephritis seen in different infectious diseases 
show some difference as far as the symptom dropsy is concerned. 
Thus in scarlet fever there is early seen a puffiness under the eyes and 
a swelling of the limbs, while in diphtheria it is rare to see any anasarca, 
even with a severe nephritis. 

The nephritis rarely seen in infants and young children, inde- 
pendently of the acute exanthemata, is sometimes called the primary 
form. This means only that the exact source of the agent that infects 
the kidneys is unknown. It may come from the tonsils or gastro- 
enteric tract. Doubtless the colon bacillus is frequently responsible. 
The few cases reported in infancy have usually shown an abrupt onset, 
high fever, vomiting, and sometimes diarrhea and a high mortality. 
In older children, the onset and course are less severe and the prog- 
nosis better. Dropsy is reported as uncommon in both varieties in 
so-called primary nephritis. 

The average duration of acute nephritis is from one to three 
weeks. The improvement in symptoms, and clearing up of the urine 
is gradual. Nephritis is usually accompanied and followed by marked 
pallor and anemia. While there is always diminution in the amount 
of urine, complete suppression is comparatively rare. The latter may 
exist for many consecutive hours and yet be followed by recovery. 
An examination of the bladder must always be made to be sure that 
retention is not interpreted to mean suppression. 

Complications. — The most frequent complications are referable 
to the heart and lungs — in the former, endocarditis and pericarditis; 
in the latter, pneumonia and pleurisy. In rare instances meningitis 
may supervene. 

Diagnosis. — The recognition of the disease must rest principally 
on careful examinations of the urine. It may be suspected when 
moderate fever and pallor exist without apparent cause. 

Prognosis. — The younger the child, the worse the prognosis. 
After three or four years of age the prospect of recovery is good, espe- 
cially if a fair amount of urine is passed and there are no marked evi- 
dences of uremia. If, however, there is a large number of casts pres- 
ent with a tendency to suppression, the outlook is graver. The 
mere amount of albumin passed is not of so much prognostic value. 
While a majority of the cases undergo complete recovery, there is 
always the possibility of chronic nephritis supervening. This must 



DISORDERS OF THE URINE AND KIDNEYS. 485 

be borne in mind in giving the ultimate prognosis and the urine should 
be examined at intervals for a long time so that such a condition may 
be early recognized. Children may have a subacute or chronic nephri- 
tis with very few symptoms, and hence the condition may be overlooked 
during a long period of apparent health, or until an acute exacerbation 
brings on a serious or fatal result. 

Treatment. — Children suffering from infectious diseases, especially 
scarlet fever, should be handled carefully as far as the organs of elimi- 
nation are concerned — particularly the bow^els and the skin. In this 
way the kidneys will be saved some of the irritation induced by the 
effort to eliminate the toxins produced by the original disease. Rest 
in bed, keeping the skin warm, and the use of mild saline laxatives, 
with milk and farinaceous foods will usually be sufficient for this pur- 
pose. When nephritis supervenes, in spite of such care, more active 
measures must be employed. These resolve themselves into a freer 
use of cathartics, diuretics and diaphoretics, with a fluid, unstimulating 
diet. The action of cathartics is usually more certain than other 
agencies. Calomel in doses of one or two grains is a good cathartic and 
diuretic as well. Citrate of magnesia, a few ounces at a dose, and 
compound jalap powder, ten grains to a child of five years, given 
every few hours, will prove helpful in relieving the kidneys through 
the bowels. Unstimulating diuretics, such as the citrate and acetate 
of potash, from two to five grains every two or three hours, are valu- 
able remedies. A teaspoonful of cream of tartar to a glass of water, 
drunk freely from time to time, is a pleasant diuretic. Sweet spirit 
of niter, from 5 to 20 drops, according to age, well diluted, occasionally 
does well. Plain water, given freely, is one of the most constant and 
valuable diuretics we possess. It should always be frequently given 
in cases of illness of all kinds in children to insure a free action of the 
kidneys. The alkaline effervescing waters, such as vichy, will some- 
times be taken in preference to plain water. Most of the diuretic 
remedies have diaphoretic effect when the skin is kept warm, while 
if the surface is cool the latter is lost and the result will be exclusively 
diuretic. In urgent cases, the muriate of pilocarpin will often have 
a most beneficial effect in producing free sweating and hence in reliev- 
ing the engorged kidneys. To a child of three years, gr. j-q or even 
To of a grain may be given every five or six hours until results are 
obtained. It may be given hypodermatically if a quick effect is de- 
sired, but, as it is depressing, stimulants must be given at the same 
time. The infusion of digitalis has a diuretic as well as stimulating 
effect, but it sometimes tends to upset the stomach. 

The hot pack affords one of the most convenient and efficient 



486 DISEASES OF CHILDREN. 

methods of acting on the skin. A blanket is soaked in hot water (110° 
to 115° F.) wrung out and packed around the patient's body. Hot- 
water bottles are put in position and the whole is surrounded by a 
dry blanket. The skin is soon bathed in a profuse perspiration, 
aud this may be repeated several times in the day if necessary. 
Hot saUne injections (105° F.) given with a fountain syringe 
and soft catheter, or a double current tube, have a very 
beneficial effect in favoring kidney action. One or two quarts 
may be thus employed several times a day. If there is a 
pulse of high tension and nervous symptoms pointing to eclampsia, 
nitroglycerin, and small doses of morphin may do good. At five 
years, grains -^^-^ to 2^-^ of nitroglycerin may be given every two or 
three hours. During convalescence, some preparation of iron should 
be given for the anemia that always ensues. The diet all through 
the disease must consist principally of milk given freely. Some of 
the variations of milk often do better than whole milk. Thus skim 
milk, buttermilk, milk and vichy, kumyss, junket, and whey may be 
tried. The various farinaceous foods mixed with milk are also desir- 
able as nourishment. 



Chronic Nephritis. 

{Chronic Diffuse Nephritis; Chronic Parenchymatous Nephritis; Large 
White Kidney; Amyloid or Waxy Kidney; Chronic Interstitial 
Nephritis.) 

Definition. — A chronic inflammation involving any or all of the 
histological structures of the kidney, but usually either prevailingly 
parenchymatous or interstitial, especially the former. 

Etiology. — It usually occurs as a sequel to one of the acute infec- 
tions, but with especial frequency after scarlet fever. The interstitial 
variety is usually seen in older children in connection with hereditary 
syphilis. Valvular disease of the heart, alcoholism, and chronic 
tuberculosis may also be noted as causes. Prolonged suppuration, 
especially of bones or joints, is usually responsible for the waxy form. 

Pathology. — In the parenchymatous form, sometimes known as 
the large, white kidney, the organ is generally enlarged, with a yellow- 
ish-white appearance on section. The renal epithelial cells present a 
swollen, granular, or fatty appearance. The tubules may be con- 
tracted or dilated, and are usually filled with casts. There is com- 
pression of the tufts in the glomeruli from proliferation of the cells 



DISORDERS OF THE URIXE AND KIDNEYS. 487 

of the capsule and increase of connective tissue. The waxy kidney 
is usually much enlarged and presents the mahogany-brown dis- 
coloration with iodin. This form of degeneration is marked in the 
capillaries of the tufts and in the smaller arteries of the kidney. In the 
interstitial form, the kidney is small, with adherent capsule and 
nodular surface. The new connective tissue is distributed through 
the kidney in an irregular manner, producing a twisting or atrophy or 
dilatation of the tubules, the latter sometimes forming cysts. The 
glomeruli may likewise be enlarged or atrophied into little fibrous 
specks. There is thinning of the cortex after the chronic inter- 
stitial change has become marked. 

Symptomatology. — The symptoms and colirse of chronic nephritis 
in the child do not differ in any essential way from the clinical mani- 
festations seen in the adult, especially as the disease is usually found 
in later childhood. In mild cases, there may be only general weari- 
ness, occasional vomiting and digestive disturbances, headache, and 
anemia. In severer cases, dropsy is a very constant symptom. 
The edema may be limited to the lower extremities and the vulva or 
scrotum, or there may likewise be effusion into the interior cavities, 
more often into the peritoneal cavity and occasionally into the pleura 
and pericardium. The dropsy is variable, sometimes being excessive 
and then suddenly clearing up for a time. Albumin is pretty constantly 
present in the urine, with hyalin, granular, and fatty casts. These 
abnormal ingredients vary in amount with the increase or decrease 
in the severity of the disease. The daily quantity of urine passed 
likewise varies from much below normal to about the proper amount. 
The progress of the disease is usually slow and very irregular, perhaps 
continuing for a number of years with occasional exacerbations when 
the symptoms become urgent, followed by periods of remission when 
the patient is comfortable. Eventually, death takes place from 
uremia or some intercurrent disease. In the chronic interstitial form, 
edema is rare, but there is the usual high tension pulse and enlarge- 
ment of the left ventricle. As in adults, the nervous disturbances 
preponderate, such as headache, neuralgia, spasmodic dyspnea, poor 
vision, and dyspeptic troubles. The urine is passed in large amounts, 
having a low specific gravity and frequentlj^ without albumin. Casts 
are not nearly so abundant as in the other and more common form 
of chronic nephritis. 

Complications. — Edema of the lungs and pneumonia may be 
considered the most frequent complications. One may also look 
for pleurisy or endo- or pericarditis. 

Diagnosis. — The most objective symptoms leading to a recognition 



488 DISEASES OF CHILDREN. 

of this condition are a marked lessening in the quantity of urine passed 
and some form of dropsy. Poor nutrition, pallor, headache, high 
arterial tension and an enlarged heart should lead to careful exami- 
nations of the urine upon which the diagnosis must ultimately rest. 

Prognosis. — Complete recovery is rare. The symptoms, however, 
may rest in abeyance for long intervals of time. The disease may last 
for three or four years and the patient eventually succumb to some inter- 
current trouble. The immediate prognosis becomes bad in the pres- 
ence of very scanty urine and extensive dropsy. 

Treatment. — The management of the case must be largely hygienic 
and dietetic. The skin must be kept warm by flannels and, if possibe, 
the patient sent to a warm, dry climate. Sudden changes, with marked 
lowering of the temperature, are liable to be dangerous. If dropsy 
is present the cathartics, diuretics, and diaphoretics used in acute neph- 
ritis may be employed. The same is true of uremic symptoms. 
General tonics, and especially iron, may be constantly given. While 
a fluid diet, principally milk, is the mainstay, it is sometimes necessary 
to allow a more generous diet, especially when anemia is extreme. 
The farinaceous foods can always be given, and it is sometimes an ad- 
vantage to give meat in moderation. If weakness is great, one must 
not persist on a too low protein diet. 



Pyelitis. 

Definition. — An inflammation of the lining membrane of the pelvis 
of the kidney, often associated with nephritis or cystitis. 

Etiology. — Congenital malformations of the kidney or ureter may 
cause pyelitis, also tuberculosis of the kidney and renal calculi. There 
may be an infectious form of pyelitis in connection with such infec- 
tious diseases as typhoid fever, scarlet fever, or diphtheria. Cases 
have been reported as caused by the common colon bacillus. There 
may be an extsnsion of inflammation from neighboring structures, 
such as the kidney or bladder. Finally, general pyemia may be re- 
sponsible for the disease. 

Pathology. — The pyelitis accompanying a general infection usu- 
ally attacks both kidneys, while a purely local irritation involves only 
one side. The inflammation involves the mucous membrane of the 
pelvis and is of an acute inflammatory nature with congestion and 
infiltration of the cells and occasionally punctate hemorrhages. Pusis 
formed and passes out with the urine. It may quickly collect in 
such an amount as to distend the pelvis and calices of the kidney^ 



I 



DISORDERS OF THE URIXE AND KIDNEYS. 489 

thus leading to pyonephrosis. A pyelitis that persists is accompanied 
by more or less nephritis. The colon bacillus is found best in a 
catheterized specimen. 

Symptomatology. — These are somewhat irregular in character. 
Pain may be a prominent symptom, especially noted during urination. 
In other cases there is no evidence of local discomfort and not much 
besides pyuria to indicate the disease. A moderate, continuous fever 
may be present or, perhaps more often, the temperature assumes an 
intermittant character and may be accompanied by chills and sweat- 
ing. In all cases of unexplained fever in early life with cachexia, this 
disease may be suspected and the urine carefully examined. The urine 
is turbid, with an acid reaction, and contains blood- and pus-cells and 
epithelial cells desquamated from the pelvis of the kidney. Albumin 
is present, sometimes from the pus and at other times as an evidence 
of accompanying nephritis, when epithelial, granular, or hyalin casts 
are also found. The urine is usually swarming with bacteria. If the 
pyelitis is of tuberculous origin, tubercle bacilli will be present in the 
urine. Occasionally large quantities of pus will be discharged into the 
urine from an abscess rupturing into the pelvis of the kidney. If the 
disease becomes chronic, pyuria may be the only constant symptom to 
be noted. These is also apt to be evidences of failure of health and 
emaciation in these cases. An examination of the blood in pyelitis 
usually reveals a leukocytosis. 

Diagnosis. — This rests finally on an examination of the urine, which 
w^hen acid and containing pus and pelvic epithelium, will make the 
diagnosis positive. Cystitis is rare in children, but examination for 
urethritis in the male and vulvovaginitis in the female must be made 
when pus is found in the urine. The acid reaction, however, in- 
dicates pyelitis. Pain in the region of the kidneys, irregular fever 
with chills and scanty urine point to pyelitis, but pyuria is the only 
constant and positive symptom. 

Prognosis. — The prognosis is good when the kidney proper has not 
become much involved in the inflammation. Where there is extensive 
nephritis from calculi or pyonephrosis ensues, the prognosis is bad. 

Treatment. — A free administration of water to which citrate or 
acetate of potash has been added will serve to flush out the kidney 
and check the acidity of the urine. Two to five grains of these alkalies 
may be given every three hours. Urotropin, in doses of two to five 
grains, three times a day, to a three-year-old child, is an efficient 
urinary antiseptic. If calculi are present and can be located, sur- 
gical treatment may give relief. The same may be true of pyo- 
nephrosis. See page 95 foi' vaccine treatment. 



490 DISEASES OF CHILDREN. 

Perinephritis. 

Definition. — An inflammation of the loose connective tissue 
around the kidney. 

Etiology. — The inflammation may be primary and due to trauma 
or possibly to cold and exposure; and secondary to suppurating foci 
within the kidney, such as may be produced by calculi. 

Symptomatology. — There may be two methods of invasion — one 
sudden, with chills, fever, a,nd pain in the region of the kidney; the 
other more gradual, with rigidity of the hip and spine and flexion of 
the femur. Pain is present and motion is accompanied by pain 
which may be referred to the knee, thigh, groin, or back. There is 
usually marked pain on making extension of the thigh, which is 
considered diagnostic. There is a constant temperature which is not 
very high at first. As the disease progresses, the spine becomes 
curved with the concavity toward the affected side, and the thigh 
is constantly flexed. Suppuration may take place and the abscess 
may burrow between the lumbar muscles behind or the abdominal 
muscles in front and be recognized as a tumor in these locations. 
The disease may last from a few weeks to a few months, and recovery 
usually quickly ensues after evacuation of the pus. 

Diagnosis. — The disease most apt to cause confusion is hip-joint 
disease. This is slow in onset, with a gradual atrophy and limitation 
of motion affecting all the movements of the joint and not coming to 
abscess much under a year. In perinephritis, the onset is much more 
sudden with deformity and abscess ensuing within a few weeks or 
months. There is no tenderness in the joint and flexion of the thigh, 
with pain on extension, is the principal deformity. Pott's disease, 
with psoas abscess, may be differentiated by an examination of the 
vertebrae for caries. 

Prognosis. — Good. The cases will recover unless the abscess 
ruptures into the peritoneal cavity. 

Treatment. — The patient must be kept quiet in the horizontal 
position. Sedatives may be given for the pain and both hot and cold 
local applications tried. An early recognition and opening of an 
abscess will usually be followed by a rapid recovery. 

Tumors of the Kidney. 

Very rarely there may be tuberculous growths in the kidney, 
usually in connection with a tuberculous infiltration of other portions 
of the genito-urinary tract. The vast majority of cases in which a 



DISORDERS OF THE URINE AND KIDNEYS. 491 

malignant growth attacks the kidney in the child are of a sarcoma- 
tous nature. The sarcomata are primary growths in these cases and 
may be followed by secondary growths in other organs, such as the 
lungs or liver. The growth may start in the pelvis of the 'kidney or 
in the adrenals or cortex. The increase in size is rapid and may 
produce pressure effects on the various abdominal viscera, with ascites 
and rarely general peritonitis. Generally only one kidney is involved. 

Symptomatology. — The tumor is usually the first symptom to be 
noted. It steadily grows until a very great size is reached. The 
growth may usually be first noted in the side of the abdomen, but soon 
pushes forward to the middle, and in a few months may fill the whole 
cavity. Hematuria is sometimes present, and there is a rapid failure 
of strength and vitality. There will be pressure symptoms according 
to the size and direction of the growth. The patients rarely live 
beyond a year, and frequently not so long unless an operation is suc- 
cessful. 

Diagnosis. — The diagnosis is made by the rapid growth of a solid 
abdominal tumor in an infant or a young child. Practically all 
tumors of this nature at this time and in this position are sarcomata. 

Treatment. — The tumor must be removed as soon as recognized. 
While the mortality is high, a certain number of recoveries have been 
reported. 

Hydronephrosis. 

Hydronephrosis is a dilatation of the pelvis and calices of the 
kidney, often associated with necrosis of the kidney parenchyma, due 
to some obstruction to the outflow of the urine. It is seen more 
frequently in early than late childhood and about half the cases are 
found to be congenital. 

The obstruction may be situated any where in the genitourinary 
tract from the external meatus to the calyx of the kidney. The fol- 
lowing causes may be noted: Imperforate prepuce or meatus; congeni- 
tal stricture of the urethra; congenital hypertrophy of the bladder 
wall inducing stenosis of the ureters; misplacement of the ureters; 
valve-like strictures in the course of the ureter or of the ostium pel- 
vicum, showing a reduplication of the mucosa and of the muscularis 
from inflammatory change or abnormalities of development; urinary 
calculi occurring after birth and, by their growth, occluding the uri- 
nary tract; pressure by abnormal growths in neighboring organs or 
mechanical pressure from a floating kidney; deformities of the skele- 
ton or any foreign body in connection with the genitourinary tract. 



492 



DISEASES OF CHILDREN. 



Hydronephrosis may be unilateral or bilateral, in the latter case 
the obstruction usually exists in the bladder or urethra. The congen- 
ital form may be either unilateral or bilateral, but is usually unilateral. 
There will be extensive dilatation if the obstruction in the urinary 
tract occurs before the fourth month of intrauterine life, as the secre- 




Fig. 130. — Bilateral congenital hydronephrosis, caused by valve-like 
strictures in the ureters. From an infant 26 days old. 



tion of urine begins about this time. When the hydronephrosis is 
unilateral, the other kidney will functionate vicariously. In some 
cases the obstruction may be only temporary or partial, when the 
affected kidney will retain part of its function. 

Cases of hydronephrosis of both kidneys are fatal during infancy, 
and the condition is usually overlooked, the babies' dying of some 



DISORDERS OF THE URINE AXD KIDNEYS. 



493 



intercurrent affection. In older children, with the unilateral form, 
the disease may be suspected or recognized when the dilatation is 
sufficient to produce a tumor in the lumbar region. Nephrectomy 
may then afford a radical cure if the other kidney is sound. Where 
hydronephrosis is due to an impacted calculus in a ureter, the con- 
dition is apt to eventuate in pyelonephritis. 



Enuresis. 

{Incontinence of Urine.) 

The symptom-complex of incontinence of urine can best be studied 
by considering, first, the phenomena which accompany the voiding of 
urine under the action of the bladder reflexes, and, second, the ana- 
tomical and physiological peculiari- 
ties accompanying this function in 
early life. 

The bladder, the spinal centers 
innervating it, and the brain hold- 
ing an inhibition over the spinal 
centers, all have a part in this ac- 
tion. The following diagram, modi- 
fied from Gowers, will give a sug- 
gestive idea of these parts: 

In the bladder w^e have the 
sphincter (S), guarding the outlet 
by its tonic contraction, and the 
detrusor (D), or muscle of the 
bladder, usually distended, but 
which, by its contraction, empties 
the organ. Both sphincter and 
detrusor are innervated by the 
segments in the spinal cord corres- 
ponding to the third, fourth, and 
fifth sacral nerves. The motor 
tonic centers for the sphincter (MS) 
keep this muscle in contraction, 
while the centers for the detrusor (MD) hold it in a state of dilatation 
corresponding to a positive and negative, or plus and minus action, 
of the motor nerves MNS and MND. As the bladder becomes 
distended with urine, sensory impulses are transmitted by sensory 
nerves (SN) to the sensory centers of the cord (SC) which are con- 
nected with the motor reflex centers (MS and MD) by association fibers. 




Fig. 131. 



494 DISEASES OF CHILDREN. 

When the motor centers are sufficiently irritated they reverse their ac- 
tion, as a negative impulse ( — ) is sent down by the motor nerves MNS 
to the sphincter, which dilates, and a positive ( +) action is transmitted 
by the motor nerves MND to the detrusor which promptly contracts. 

The action of a physiological, automatic reflex is thus shown. 
This action, however, is held in check by the inhibition of the brain 
(B) that holds a restraining influence on the spinal reflexes by nerve 
fibers connecting with them (MT and ST). It is usually necessary 
to relax the inhibition of the brain before the automatic reflex can take 
place. Urination is, therefore, not so much a direct voluntary action 
as an indirect action of the brain in relaxing its hold on the spinal 
centers and thus allowing the automatic reflex full sway. 

In early life there are certain anatomical and physiological pecu- 
liarities that render the bladder and its reflexes very unstable. While 
the sphincter is weak, the detrusor is thick and powerful. In making 
autopsies on female infants the bladder, owing to the thickness of its 
wall, is sometimes mistaken for the uterus. A powerful detrusor 
acting against a feeble sphincter thus renders the action of the bladder 
in retaining the urine unstable. In early life the spinal reflexes are 
also very active. The motor areas of the cord are relatively more 
developed than the sensory part, and hence motor actions preponder- 
ate. What would cause a sensory disturbance in an adult is reflected 
into a motor arc in the child and hence produces a motor disturbance. 
This is exemplified in the beginning of severe illness, especially in 
acute infections, where the chill (sensory disturbance) of the adult 
is often replaced by a convulsion (motor disturbance) in the child. 
This activity of the motor reflexes exhibits many forms in early life, 
especially in infancy, when the action of the spinal cord is most active, 
and the brain being as yet undeveloped fails to hold a proper inhibition 
on these lower centers. The watery brain of the infant, with rela- 
tively little gray matter, cannot hold the active reflexes of the spinal 
centers in proper equilibrium. 

There are two forms of incontinence — active and passive: (a) 
Active incontinence is produced when sufficient urine is present in the 
bladder to cause enough irritation of the sensory nerves to induce a 
contraction of the detrusor and dilation of the sphincter through the 
spinal centers. There is no paralysis, but either a lack of proper brain 
control or overaction in the cord. In this form the urine usually 
passes rapidly and in full stream, (b) Passive incontinence is caused 
by weakness or paralysis of the sphincter, and the urine usually 
dribbles away without ability of control. 

With the constant underlying predisposition to incontinence in 



DISORDERS OF THE URINE AND KIDNEYS. 495 

early life, there are certain specific causes that may be mentioned in 
order to throw light on treatment: (1) Excessive acidity of the 
urine. Uric acid is readily formed in early life; in new-born infants 
crystals are often seen in the calices of the kidney. The urine may 
thus become so irritable as to be passed drop by drop, or with a 
reddish tinge that simulates the appearance of blood on the diaper. 
Other acids, such as the acid phosphate of sodium and lactic and 
hippuric acids may be present in excess in the urine. Very small 
quantities of overacid urine often provoke incontinence by irritating 
the bladder, and thus stimulating the nerve reflexes to act. (2) 
Excessive irritability of the muscular coat of the bladder even when 
the urine is mildly acid or neutral. As the detrusor has an exaggerated 
contractile power in these cases, the urine is passed in a full and rapid 
stream. Even ordinary stimulation often causes strong contrac- 
tion in the unstriped muscular fibers. This explains why atropin or 
belladonna acts almost as a specific when the muscle is thus at fault. 
(3) Weakness of the sphincter. This form occurs in feeble children 
who are in poor condition from severe illness or underfeeding, or 
where the innervation of the sphincter has been weakened by diseases 
of the spine or spinal nerves. The urine is not passed rapidly nor in 
full stream, but is more apt to dribble away. (4) Reflex irritation 
from disturbances outside the bladder. The genitals, anal ring or rec- 
tum may present conditions producing sufficient irritation to cause fre- 
quent contractions of the bladder under reflex action. Phimosis, adhe- 
sions of prepuce to glans with retained smegma, stricture of the urethra, 
balanitis, vulvitis, ascarides, fissure of the anus and hard scybala in 
the rectum may be noted in this connection. (5) Neurotic causes. 
Children with unstable nervous equilibrium from chorea, epilepsy, 
and similar conditions are prone to incontinence of urine. Under 
psychical influence, especially in dreams, the child imagines a con- 
venient place for urination and the reflexes act. (6) Vesical calcidus 
may be a rare cause of incontinence, and, when acting, will be both 
diurnal and nocturnal, with urine turbid from mucojDus and frequent 
painful micturition. (7) Malformation of the bladder. Congenital 
deformities, such as extroversion of the bladder, rectovesical and 
vesicovaginal fistulse, and a few cases reported where ureters have 
emptied directly into the urethra, will be accompanied by constant 
dribbling of the urine. 

Treatment. — It is evident from an enumeration of the different 
causes that one kind of treatment will not be adapted to all cases, and 
hence the physician must find, if possible, the principal reason for 
incontinence by an examination of the urine, together with a general 



496 DISEASES OF CHILDREN. 

and local physical examination of the patient. More than one cause 
will often be found present. Highly acid, scanty urine may be 
relieved by a free administration of water together with an alkali, 
such as the acetate or bicarbonate of potash, five grains of either 
thrice daily. Where overirritability of the detrusor is the principal 
cause, belladonna in full physiological dose, by its action on unstriped 
muscular fiber, will usually diminish functional activity and thus 
correct the condition. For a child of five years, grain 4^-0 atropin 
sulphate or the tincture of belladonna, rr[. v, may be given late in the 
day, and the dose increased until there is dryness of the throat and 
flushing of the skin. If the incontinence is not relieved when the 
drug is pushed to its full effect, it will not be necessary to continue it 
very long. Where there is evidence of weakness of the sphincter, nux 
vomica or strychnin and ergot will act in strengthening its tonicity 
and stimulating the nerve centers. From 5 to 10 minims of fluid 
extract of ergot and 5 minims of the tincture of nux vomica may be 
given thrice daily, well diluted in water, to a child of five years. 
Unlike belladonna, these remedies may have to be continued for sev- 
eral weeks before the full benefit is obtained. Occasionally good 
results will be obtained by a few hypodermatic injections of ten drops 
of the fluid extract of ergot directly into the ischiorectal fossa. Sup- 
positories, containing half a grain of ergotin, may also do good in this 
class of cases. Incontinence of feces may have the same nervous 
causes and mechanism as incontinence of urine and may require the 
same treatment. 

The general hygienic treatment is always important. A simple, 
unstimulating diet, with a light early supper is desirable. Restriction 
in the amount of fluids, especially late in the day, may be tried. 
Postural treatment at night, with the buttocks elevated to save the 
neck of the bladder, has been advised, but is impracticable. General 
tonic treatment, such as the use of large doses of the syrup of the iodid 
of iron will relieve certain cases. Cold bathing, and plenty of fresh 
air will act as adjuvants. Sometimes a change from one bed to another 
will bring at least temporary relief. The children should be taken up 
late at night and early in the morning, and placed upon a commode 
to prevent the bladder from getting too full. Punishing these children 
is unavailing and usually makes the matter worse by upsetting the 
nervous system. The trouble is apt to be more frequent and intract- 
able in boys than in girls, and in rare cases may last for years. An 
intelligent study of the child's condition and a recognition of the 
principal cause in each case and an adaptation of the treatment to 
such specific cause will, however, usually bring relief. 



SECTION XII. 

DISEASES OF THE GENITAL ORGANS 
AND BLADDER. 



CHAPTER XXXIV. 
DISEASES OF THE GENITAL ORGANS. 

Phimosis and Paraphimosis. 

Phimosis exists when the prepuce is so narrowed or contracted 
that the foreskin cannot be freely drawn back over the glans. 

Hofmokl notes four causes of phimosis: 

(1) A prepuce congenitaUy too long and too narrow (hypertrophic 
form), (2) congenital narrowness restricted to the external opening of 
the prepuce, (3) long persistence of extensive epithelial agglutination 
between glans and prepuce, (4) congenital and abnormal shortness 
of the frenulum and its location too far toward the front. 

Symptomatology. — Urination is frequent and painful. When 
about to urinate the child is very restless, and while voiding will often 
cry out with pain. Older children attempt to restrain the act as long 
as possible. In some cases the prepuce balloons out with urine as it 
passes or it may escape drop by drop. If the foreskin is very tight, 
drops of urine remain and decomposition of this retained urine often 
produces an eczema at the meatus or even on the thiighs and over the 
entire genital region. Such inflammatory processes may cause balan- 
itis. The habit of masturbating may be induced by the irritation. 
Following such a course, an infection may occur which may ascend 
through the urethra, sometimes, although rarely, causing urethritis 
and cystitis. Dilatation of the bladder and hydronephrosis may also 
result in neglected cases. The increase of intraabdominal pressure 
from straining may produce a hydrocele, a hernia, or prolapse of the 
rectum. Syncope and epileptiform convulsions were formerly erro- 
neously attributed to phimosis. 

If the foreskin be forcibly retracted over the glans, the pres- 
sure of the preputial ring in the coronary sulcus may cause strangula- 
tion. Such a condition is known as paraphimosis and soon causes 
violent pain. If this obstruction to the circulation is not relieved 
32 497 



498 DISEASES OF CHILDREN. 

edema and inflammation will occur which later can produce ulceration 
and necrosis of the parts. 

Treatment. — The treatment of phimosis with adhesions consists 
in gently separating the agglutinated surfaces with a blunt probe and 
then retracting carefully the foreskin over the gians. If this is not 
easily accomplished the foreskin may be stretched by slowly separating 
the blades of a forceps until it is possible. Any smegma which is 
present is wiped away. If urine is retained in the foreskin causing 
decomposition, circumcision is indicated rather than stretching. To 
relieve a paraphimosis, replace the glans within the prepuce by using 
the first and second fingers of both hands from below and with the 
thumbs above, forcing the glans through the constriction. If this 
cannot be accomplished by manipulation, the strangulating ring must 
be incised and cold compresses applied to reduce the swelling and in- 
flammation. As a rule, circumcision is performed at a later date. 

Balanitis. 

This condition is usually due to an accumulation of smegma and 
retained urine, the decomposition of which causes an inflammation of 
the prepuce. Such accumulations occur most frequently where there 
is phimosis. Other causes of balanitis are masturbation, injury, and 
infection of the mucous membrane of these parts. There is redness 
and swelling of the free margin of the prepuce, the opening of which is 
often covered by small crusts. Several drops of seropus may appear 
if the opening of the prepuce is separated; it is usually impossible to 
retract the prepuce entirely. 

Treatment. — Distend the prepuce by injecting an antiseptic solu- 
tion, such as bichlorid of mercury, 1 to 5,000, or a weak permanganate 
of potash solution, three or four times a day. When this cannot be 
accomplished, apply the antiseptic dressing ice-cold. A solution of 
bichlorid of mercury 1 to 10,000 or liquor Burowi, one to four parts, 
is suitable. The wet dressings are applied until the swelling is reduced. 
Slitting up the prepuce to permit of thorough cleansing is sometimes 
necessary and then gives the quickest relief. All adhesions should be 
removed when this is done. Circumcision at this time should not be 
performed. 

Urethritis. 

Urethritis may be simple or specific. In the former, lack of 
cleanliness, injury or uric acid crystals are the usual causes. There is 
pain on urination and a slight discharge of pus. The inflammation is 



DISEASES OF THE GENITAL ORGANS. 499 

usually confined to the anterior portions of the urethra. There are no 
sequela? as in the specific form. 

Infection causing specific urethritis takes place by direct con- 
tact and can be diagnosticated only by a bacteriological examination. 
Gonococci are generally found in great numbers in the discharge. 
Except for the constitutional symptoms, which are mild or entirely 
absent, specific urethritis gives the same clinical picture as in adults; 
that is, a thick purulent discharge and burning pain on urination. 
Complications are rare; those likely to arise are stricture, posterior 
urethritis, epididymitis, arthritis, and gonorrheal conjunctivitis. 

Treatment. — Urotropin in 5-grain doses three times a day with 
rest in bed is usually sufficient, but in some obstinate cases it is neces- 
sary to irrigate the urethra with argyrol in a 5 per cent, solution or 
potassium permanganate in | per cent, solution twice daily. The 
pelvis should be covered to avoid carrying the infection to the eyes 
and the attendants warned of such danger. 

Vulvovaginitis. 

( Urogenital Blennorrhea.) 

This condition is a frequent cause of dysuria in girls, and may 
occur under the influence of general malnutrition, as in marked 
anemic conditions, uncleanliness, masturbation, when parasites are 
present, or following an infectious disease. The usual cause, however, 
is an infection by Neisser's gonococcus. 

In this specific form infection takes place by either direct sexual 
contact or by handling, contact with the infected bed linen of parents, 
and less frequently from towels or discarded dressings. Epidemics 
of vaginitis frequently occur in hospitals and especially institutions for 
children. 

Differentiation of the simple and gonorrheal types is based on 
the bacteriological examination of the pus. 

Vulvovaginitis begins with redness and swelling of the parts and 
a discharge of pus, which is usually yellowish or white in the simple 
form and greenish in the gonorrheal. The pus is abundant, and on 
drying forms crusts causing the labia to adhere. Micturition is 
frequent and painful, due to contact of the urine with excoriations 
of the mucous membranes of the urethra and the labia. There is also 
pain on locomotion, due to the excoriated thighs. In severe cases 
pus may be seen oozing from the cervix. The vaginal mucous mem- 
brane bleeds easily, due to the excoriations present. Constitutional 
symptoms are infrequent, but buboes occasionally occur and may even 



500 DISEASES OF CHILDREN. 

suppurate. In the gonorrheal form the usual adult complications 
may occur, such as arthritis of the large joints, conjunctivitis, and 
cystitis. Salpingitis and general peritonitis have occurred in our 
service. 

Treatment. — Treatment of all vaginitis cases requires isolation 
of the case and scrupulous cleanliness as regards the patient, the linen, 
and the dressings as well as the attendant's hands. In severe cases 
the patient should be in bed. In the simple form, after removing the 
cause, irrigate the parts two or three times daily with warm normal 
salt or boric acid solutions, bichlorid of mercury 1 in 10,000, silver 
nitrate solution 1 in 10,000, or formalin solution 1 in 5,000. Cover the 
thighs and vulva with unguentum zinci oxidi or stearatis. A sterile 
pad is applied over the parts. 

In gonorrheal cases this treatment may be supplemented by the 
use of vaginal suppositories of argyrol 10 per cent, in oleum theobro- 
matis; insert one after each irrigation. In all cases general tonics are 
indicated. 

In simple cases under treatment the course of the disease is 
about two or three weeks. The gonorrheal form lasts much longer, 
often for months, and relapses are frequent. 

Vaccine Treatment. — The vaccine treatment may be tried in 
intractable cases or for a series of cases in an institution. A study 
of recent investigations shows that the injections of vaccine must be 
controlled by determination of the opsonic indices of each individual 
case, reinjection being made before the index falls below normal. 
A dose too large or two small gives little or no response, five million 
dead bacteria being the preferred initial dose. Under this treatment 
clinical evidences of gonorrhea disappear in ten to twenty-one days, 
and no gonococci can be found in the smears for some time. 

In some cases a polyvalent vaccine seems more efficient than a 
univalent one. The best results are obtained when the vaccine used 
is obtained from the patient's own organisms, except where the case is 
of long duration or has been treated by antiseptics, as these lower the 
virulency of the organism; it is then better to make vaccine from a 
strain of known high virulence. Experiments have proved this 
step to be most efficient in spite of Torrey's conclusion that ''the 
family gonococcus is heterogeneous." 

If an eye should become infected, the injections should be made 
at once without determining the index or waiting for the vaccine to be 
made. 

The frequency of injection depends on the index; nothing can be 
gained by more injections during the negative phase. If the initial 



DISEASES OF THE GENITAL ORGANS. 501 

dose be high the negative phase may last two weeks or longer. It is 
therefore better to wait a longer rather than a shorter time for the 
second injection. As a rule, the discharge increases for the first two 
or three days after the injection, and then diminishes very rapidly. 
Improvement is always marked after the first few days, and the patient 
may continue to gain during the negative phase; consequently clinical 
signs should not be made the guide for future injections. Index 
determinations alone must be depended upon. 

Masturbation. 

In infants and very young children, the presence of some organic 
source of irritation in or about the genitalia is assumed as the cause of 
masturbation. Of such irritations itching, vulvar eczemas, and pin 
worms which have escaped from the rectum and found their way into 
the vagina are the most frequent causes in girls. Attempts to relieve 
this irritation by scratching or rubbing the thighs together results in 
the persistence of the habit because of the sensations it produces. 
In boys, an elongated prepuce, friction from a phimosis, excoriations 
at the meatus from a highly acid urine may be the original cause. 
In girls, adhesions about the clitoris from smegma and uncleanliness 
are common causes. 

In older children the beginning of such a habit is more probably 
due to acquaintance with others with whom the practice is in vogue; 
in some cases, accidental discovery that genital irritation produces 
voluptous sensations occurs in certain sports, such as bicycle-riding 
or tree-climbing. 

It is an error to assume that this practice produces nervous, 
irritable children, wdth pallor, headache, and sickly appearance and 
dark rings under the eyes unless masturbation be indulged in to excess. 
In children of the neurotic type such symptoms are, however, greatly 
aggravated by the violent sexual excitement so produced. 

Treatment. — It is essential to remove the cause. By the use of 
suitable night gowns and bandages children can be prevented from 
masturbation at night. During the day constant supervision is 
imperative; this is more difficult with children of the school age. 
Dietetic changes and psychic treatment after suitable explanation 
are potent factors in eradicating the habit. Effort should be made 
to keep the child occupied all the time and frequent diversion of the 
mind toward active and healthy normal channels will prove most 
efficient measures. Cold affusions to the spine may be employed 
in intractable cases. 



502 DISEASES OF CHILDREN. 

Hydrocele. 

When the peritoneal sac surrounding the testicle and epididymis 
is distended with fluid, the condition is known as hydrocele. It is 
not uncommon, and is usually congenital in origin. 

The following varieties may be differentiated: 

Hydrocele or the Tunica Vaginalis (with the funicular process 
obliterated). — This is one of the most common forms found in children. 
The tumor formed is oval and is firm and tense. It may occur on 
one or both sides. The tumor cannot be reduced. Fluctuation can 
usually be obtained, and the site of the testicle can be seen by illumina- 
tion of the scrotum. The cord is felt above the rounded upper portion of 
the swelling, and the testis is generally situated posteriorly, projecting 
into the cavity, and is therefore not readily detected by manipulation. 

Congenital hydrocele exists when the funicular process is 
patent. The signs above stated exist except that upon manipulation 
the fluid can be returned to the abdominal cavity. 

Infantile hydrocele occurs when the funicular process is 
closed at its upper extremity only. The fluid extends along the cord, 
and the tumor is therefore elongated; the other signs art? the same 
as given above. 

Encysted hydrocele of the cord is one in which there is an 
additional point of obliteration of the intraabdominal portions of 
the funicular process above the internal abdominal ring; fluid distend- 
ing this portion of the canal forms a tumor resembling a cyst in addi- 
tion to the tumors in the scrotum. 

Treatment. — As a rule, no treatment is required. After several 
weeks the condition spontaneously disappears. If phimosis is present 
this should be corrected at once. In more resistant cases puncturing 
the sac and allowing the fluid to thoroughly drain off usually produces 
a cure. If relapses occur, instillating one or two drops of the tincture 
of iodin in ten drops of water will set up adhesions sufficient to ob- 
literate the sac. In some of the congenital forms, a truss may be applied 
in order to obliterate the funicular process, and then if a cure is not af- 
fected aspiration is performed. If the hydrocele is associated with a her- 
nia a suitable truss must be worn after the evacuation of the fluid. 

Undescended Testicle. 

{Cryptorchidism.) 

When not in the scrotum, the testis may be found (1) in the ab- 
dominal cavity attached to the abdominal wall or (2) just inside the 



DISEASES OF THE GENITAL ORGANS. 503 

internal abdominal ring or (3) as is most common, in the inguinal canal 
or (4) just beyond it. 

The causes of such a malformation may be a short or abnormally 
attached gubernaculum, a contracted external ring, or an abnormally 
large epididymis. 

The diagnosis is made when the scrotum is found empty on the 
affected side, and a small movable tumor the size of a hazelnut is found 
in the inguinal region which gives the unpleasant testicular sensation 
on pressure. 

If no symptoms arise the best treatment is neglect; if, however, 
there is much pain or tenderness which sometimes occurs when the 
testicle is in the canal, surgical intervention is required. The surgeon 
may succeed in drawing the testicle down into the scrotum or he may 
be obhged to replace it in the abdomen. 

If the testicle lies within the abdomen and develops there, its 
function is not interfered with. When it is subjected to constant pres- 
sure within the inguinal canal, such compression may hinder develop- 
ment or lead to atrophy. 

Differential Diagnosis of Swellings in the Inguinal Region. 

Swellings in the inguinal region are either fluctuant or non-fluc- 
tuant. If fluctuation be present the tumor may be an abscess or a 
hydrocele. If an abscess be probable, there may be a history of vulvo- 
vaginitis, urethritis, scabies, or other irritant lesions about the genitals, 
and the patient will have some degree of increased temperature and 
a leukocytosis. Caries of the vertebra may produce a psoas abscess. 
If hydrocele be suspected, the history may show that the tumor has 
persisted since birth or that there has been an injury. The tempera- 
ture and the blood count will be normal, and the light test will be 
positive. On percussion of a hydrocele or an abscess the note is dull 
and not tympanitic as it may be in hernia. A hydrocele with patent 
funicular process may recede under moderate pressure, but no gurgling 
is felt as in the reduction of hernial contents. 

In tumors without fluctuation, hernia, undescended testicle, or 
enlarged inguinal glands may be suspected. 

If the condition be hernia, the percussion note is resonant; if 
reducible, the tumor disappears quickly and is accompanied by a 
gurgling sound; the external abdominal ring is patent and there is an 
impulse on crying or coughing; there is opacity when tested by trans- 
mitted light. 

If the tumor is an undescended testicle, the corresponding side 



504 DISEASES OF CHILDREN. 

of the scrotum will be found empty; the tumor is dull on percussion, 
freely movable, and hard. On pressure, the characteristic testicular 
sensations can be elicited in older boys. 

If the swelling is due to the presence of enlarged inguinal glands 
there will probably be an existing cause found in the genital region, such 
as eczema, vulvovaginitis, scabies, etc. Such tumors are dull on 
percussion, and hard and freely movable unless suppurating. In these 
cases the testicle will be found in its normal place. Enlarged glands 
are usually multiple. 

Frequently hernia and hydrocele occur simultaneously, and in 
such cases the diagnosis is more difficult. 



CHAPTER XXXV, 
DISEASES OF THE BLADDER. 

Cystitis. 

In infants, two forms are distinguishable, one presenting general 
symptoms, including restlessness, anorexia, fever, pallor, and debility, 
but without urinary symptoms; the other with the above general pic- 
ture, but with sj^mptoms showing urinary involvement, such as in- 
creased frequency of urination, pain or difficulty in voiding, abdominal 
colic, tenderness over the bladder, and redness about the meatus. 

A frequent cause of cystitis is infection by the bacillus coli, 
either alone or in mixed infection, and such infections are termed coli- 
cystitis. Many other organisms are also found as the causative factor 
but are of far less frequent occurrence. 

In colicystitis, the urine shows the following characters; it is 
turbid, acid in reaction, and contains albumin (usually less than -^-f-^ 
per cent.) pus-cells and bacteria, a pure culture of bacillus coli being 
frequently obtainable. The acid reaction of the urine in cases of cysti- 
tis signifies infection by the bacillus coli or the bacillus tuberculosis; 
the latter is ver}" rare as a primary infection, but does occur with general 
tuberculosis or when the kidneys or genitals are involved in tubercu- 
lous lesions. 

When due to infection by the pyogenes, the reaction is alkaline. 
In cases of such origin, the symptomatology is much the same as in 
colicj'stitis, but the disease is more severe. In pyogenic infections, 
blood is often found in the urine. Pfaundler's thread reaction may 
be of service in doubtful cases (see p. 58). 

Treatment. — The remedy par excellence for c^^stitis is hexamethj- 
lenetetramin (urotropin) ; infants may be given two grains every four 
hours; older children 5 to 7^ grains every four hours. Salol in the 
same doses is also useful, but not quite as effective. Chronic cases may 
require irrigation of the bladder; in such cases boric acid solution 1 
per cent, or silver nitrate solution 1 in 5,000 are the best solutions to 
use. 

In all cases give plenty of alkaline waters to drink, avoid salty 
foods and spices, and keep the patient in bed while the acute symptoms 
persist. 

505 



506 DISEASES OF CHILDREN. 

Vesical Spasm. 

Spasm of the sphincter muscle of the bladder often occurs in 
young children due to a variety of causes; for example, dysentery, 
anal fissure, parasites, inflammations in the neighboring parts, as Pott's 
disease, and lesions in the rectum, pelvis, or perineum. Occasionally in 
older children a brief spasm occurs due to certain drugs, such as tur- 
pentine, or to sudden exposure or local chilling, as a cold closet. The 
usual cause of spasm of the sphincter is the irritant effect of a highly 
acid or concentrated urine on the bladder walls. The most prominent 
symptom is frequent micturition, each act often yielding but a few 
drops of urine. Pain is severe and is accompanied by marked vesical 
and rectal tenesmus, but no blood is present in the urine. 

Treatment. — Treatment consists in the removal of the cause in 
conditions other than that due to the urine itself. When the spasm 
is due to the urine, the treatment consists in copious draughts of 
alkaline water and the administration of potassium acetate or citrate 
in doses of two to five grains with the tincture of belladonna or the 
tincture of hyoscyamus one to four drops every two or three hours. 

Vesical Calculus. 

The severest dysuria of the chronic type may be produced by a 
vesical calculus. This condition rarely occurs in children, while in 
infants it is still less frequent. A sudden stopping of the stream of 
urine is the most characteristic symptom, although diurnal inconti- 
nence is occasionally the evidence which may call to mind the possi- 
bility of the presence of a calculus. Pain on urination often occurs 
and is usually felt in the end of the penis or in the perineum. Rectal 
tenesmus with prolapse is frequently present, due to straining when cal- 
culi exist. On account of the genital irritation in this condition mas- 
turbation is often practised. Urinary changes differ from those in 
adults in that hematuria is rare, and pus and mucus are infrequent or 
occur in small quantities. A positive diagnosis is- made when the 
stone is felt by bimanual rectal examination or by searching the 
bladder with a sound or wax-tipped catheter. 

The treatment is surgical. Removal through suprapubic incision 
is usually necessary. 



SECTION XIII. 
DISEASES OF THE NERVOUS SYSTEM. 



CHAPTER XXXVI. 

GENERAL NERVOUS DISEASES. 

General Consideration. 

To the unstable equilibrium of the rapidly developing brain, 
to its peculiar sensitiveness to peripheral irritation, to the important 
role played by the infectious diseases, the liability of the child to trau- 
matism, and finally to hereditary influences, singly or combined with 
any of the above, must be attributed the many neurotic disorders 
which are peculiar to early life. 

A full and detailed histor}- will be of great assistance in arrii-ing 
at a diagnosis in this class of cases. A careful and complete physical ex- 
amination should be made with the child entirely naked. Trained ob- 
servation for details coupled with logical reasoning will be required for 
success in many instances. Certain cases if once seen in life are rarely 
mistaken, as, for example, cretinism; on the other hand, an unusual case 
of multiple neuritis may require a complete knowledge of the methods 
of examination, and the diagnosis vrill have to be supported by a 
differential diagnosis, consciously or unconsciously made by the 
physician. The sensory disturbances are elicited with difficulty in 
early life, and the muscle tone must be interpreted also from the 
view-point of the history of previous feeding. 

The gait should be carefully obserA^ed, as some are quite charac- 
teristic of certain groups of cases, for example, the cross-legged pro- 
gression, or scissors position, indicates a spastic paraplegia. The 
spastic gait is seen in cerebral palsies, while the ataxic gait is assumed 
by children suffering with cerebellar disease, neuritis, or the more rare 
disease, hereditary ataxia. The swinging gait of poliomyelitis is 
distinguishable from the waddling, swaying gait seen in those with 
the various dystrophies. As the cooperation of the patient is not 
always obtainable and the mother's statements may be innocently 
misleading, tests should be made for blindness and hearing. A candle 
or bright-colored objects may be presented to the eyes as a test. 

507 



508 DISEASES OF CHILDREN. 

Vision may be tested with the cards described on page 598. The 
finger will be allowed to touch the eyeball in absolute blindness, 
but if the corneal reflex is present there will be prompt closure. An 
ophthalmoscopic examination is feasible after proper preparation with 
atropin. Mummying the child as for intubation may be necessary 
with intractable children. It should be recollected that inequality 
of the pupils and even nystagmus may be congenital. 

The hearing may be estimated by clapping the hands suddenly 
behind the child, by the use of a whistle, or the whispered voice. 
Where an intelligent response may be expected the tuning-fork can 
be used. Tickling or pinching the toes or fingers may be used as 
a test for actual paralysis. It should be remembered that both upper 
extremities are rarely paralyzed in children. That the patellar reflex 
may be obscured by fatty deposits, and that it should be relied upon 
only after obtaining the same result after repeated tests. Ankle 
clonus, however, is always indicative of an abnormal 'condition. The 
superficial reflexes are of little or no value in the early years. The 
B'abinski reflex, extension of the big toe, is of no significance in the 
first year of life, being normal during this period. 

When the electrical examination is made in children, great care 
should be employed not to frighten the patient; allowing them to 
play with the electrodes at first is a good plan. Use the mildest cur- 
rents that will produce results, and compare the reaction to the oppo- 
site extremity. The behavior of the muscle in reacting is often suffi- 
cient to appreciate degenerative changes. 

Paralysis in General. 

Paralysis or the loss of motor power may be associated with 
sensory and reflex disturbances and with atrophy of muscle. The 
motor inability may be localized and result in a monoplegia, that is, 
a paralysis of one extremity, diplegia in which both sides are in- 
. volved, paraplegia in which the two lower limbs are paralyzed, and 
hemiplegia or a paralysis of one half of the body. 

Again paralyses are spoken of as central when they are due to 
lesions of the brain. Spinal, when they originate in the cord; periph- 
eral, when the result of nerve or muscle disease. 

General Characteristics of the Various Types— Cerebral Paralysis 
(Spastic Paraplegia). — This is commonly unilateral, the lesion being 
on the opposite side of the cortex; the face is partially involved. 
Spasticity, increased reflexes, sfight electrical changes and no atrophy 
of muscle distinguish this type. 



GENERAL NERVOUS DISEASES. 



509 



Spinal Paralysis. — Flaccidity with wasting of muscle indicates 
involvement of the peripheral motor neuron. There is no disturbance 
of sensation -(except in myelitis). The reflexes are absent or dimin- 
ished, and the reaction of degeneration is present. 

Nerve Paralysis. — The toxic forms are apt to be bilateral in distri- 
bution^ the reflexes are lost and so also is muscle excitability. The 
traumatic paralyses are due to pressure on the nerves, as a result of 




Fig. 132. — Volkman's ischemic paralysis, following fracture of the radius. 

fracture, dislocation, and pressure from without. They are local in 
distribution and if there is response to electrical stimuli, the nerve re- 
covers its function. 

Muscle Paralysis. — The motor inability is here due to the changes 
in the muscle fibers themselves. There is diminished electrical reac- 
tion and atrophy or pseudohypertrophy of muscle. Diseases of the 
joints, bones, and tendons may by atrophy and disease produce a 
paralytic condition, as in rheumatoid arthritis. 

Pseudoparalysis. — True paralysis may be simulated by muscle 
weakness, as in rachitis or chorea. Close observation and the electri- 
cal reaction easily distinguish the condition. 



Convulsions. 

{Eclampsia Infantum.) 

This symptom or symptom-complex results from a cerebral irrita- 
tion producing a temporary unconsciousness, attended by irregular 
muscular contractions. 



510 DISEASES OF CHILDREN. 

The symptom in the infant and young child often corresponds to 
the chill of the adult. It is quite commonly observed because of the 
relatively greater excitability of the brain and the undeveloped 
power of inhibitory control. We may divide the causative factors 
into two groups — the reflex or functional and the organic. 

Etiology. — The peripheral disturbances which may cause a con- 
vulsive seizure are many and various. The susceptible age is in the 
first two years of life. An apparently trivial cause, such as psychic or 
sensory impressions resulting from unusual excitement in a child with 
an inherited unstable equilibrium, may produce a typical seizure. 
Foreign bodies in the nose or ears, traumatism, intestinal parasites, 
preputial abnormalities, improper or indigestible articles of food, 
poisons, and the toxemias resulting from or preceding certain diseases, 
as rachitis, malaria, or tetany, are among the causes producing con- 
vulsions. Rachitis deserves special mention as an underlying predis- 
posing cause because of the nervous instability it produces. 

The organic causes are meningeal hemorrhages at the time of 
birth, tumors of the brain, cerebral abscess, hydrocephalus, and the 
various forms of inflammation of the brain or its coverings. It 
should be recollected that regional as distinguished from general 
convulsions are indicative of organic lesions, and also that re- 
peated seizures over prolonged periods are characteristic of cortical 
disease. 

Description of the Symptom-complex. — The attack begins without 
warning. It may be preceded by slight twitching of the face and. 
rolling of the eyes. There is then unconsciousness, the eyes are 
fixed and staring, tonic rigidity of the head, back, and extremities is 
shortly followed by clonic contractions of the facial muscles. These 
usually begin at the mouth, causing grimaces and distortions of ex- 
pression and some frothing. The teeth are firmly set. The color is 
dusky. In a general convulsion all the extremities show clonic con- 
tractions and purposeless activity. The pupils are usually dilated 
and do not react to stimuli. \ The respirations are labored, affecting 
the pulse and causing irregularity of the heart action and increasing 
the cyanosis. ^ There may be involuntary passage of urine and feces. 
After a variable time the muscular twitchings cease and the child 
passes from a coma into a deep sleep. The attacks may be and 
usually are shortly repeated unless influenced by treatment. After 
a period of sleep the child arouses and takes a normal interest in its 
surroundings; it may then be considered free from the danger of 
another immediate attack. 

Prognosis. — This is usually good, but should be guarded until 



GENERAL NERVOUS DISEASES. 511 

a definite cause is established. It is always serious if the attacks 
occur in the new-born in advanced childhood, or if they are unduly 
prolonged and recur often. If convulsions usher in a disease they are 
not of as great prognostic importance as when they occur in the 
course of the disease. An exception to this statement must be made 
in cerebrospinal meningitis in which initial convulsions are of bad 
omen. 

Differential Diagnosis. — The essential characteristics are tempo- 
rary unconsciousness and irregular muscular contractions. 

In convulsions from organic causes, the regional involvement, 
often neuritis, and the resulting paralysis may be distinguishing 
features. Epileptic seizures occur usually after the second year 
of life, they are apt to recur after longer periods and without an 
immediate causative factor. The history of predisposition may be 
obtained. 

Treatment. — ^First overcome the attack or symptom. Some one 
in the family will in all probability have given a mustard bath before 
the arrival of the doctor. If the attack persists inhalations of a few 
drops of chloroform may be given and if there is any fever an ice-bag 
is placed to the head. Meanwhile a soap-suds enema is prepared and 
given on general principles. If there is an elevation of temperature, 
the enema may be given cool at 70° F. Examine the fecal discharge 
for a possible etiological factor as some foreign substance ingested or 
for intestinal parasites. Keep the room noiseless. Follow the enema 
by a rectal injection of the bromid of soda grains ten, and chloral 
hydrate grains three, for a five-year-old child, if the twitching still 
persists. When the child can swallow, calomel or castor oil is given 
to rid the intestinal canal of possible toxins. 

In the period of quiescence obtain a careful history, make a 
detailed examination and arriving at a diagnosis order such treatment 
as is suited to the underhdng cause as, for example, a properly 
balanced diet with sufficient proteins and fats for rachitis. 

Chorea. 

(St. Vitus' Dance; Sydenham' s Chorea; Chorea Minor.) 

Chorea is a neurotic affection, characterized by purposeless move- 
ments of various parts of the body. 

Etiology. — Girls are more often affected than boys. It appears 
most frequently from the fifth to the twelfth years of life. Rheu- 
matism and tonsillitis are antecedent causes. It may develop as a 
result of fright, excessive school duties, intestinal autointoxications, 



512 DISEASES OF CHILDREN. 

or imitation of other choreic children. The offspring of neurotic 
parents are especially predisposed. 

Pathology. — The theory that rheumatism^ chorea, and endocardi- 
tis are related in many instances is gaining ground, and is certainly clini- 
cally of value. The toxin of rheumatism may affect the heart or the 
cortex of the brain in the Rolandic area, and causing irritation produce 
the characteristic movements seen in chorea. 

Hypertrophied tonsils and valvular disease are not infrequently 
associated with chorea. The infectious theory is held by the majority 
of pathologists to-day and these same observers believe in the infec- 
tious character of rheumatism and endocarditis. 

Symptomatology. — The symptoms usually come on insidiously, and 
may not be noticed until quite marked. The child is chided for care- 
lessness or awkwardness in dropping articles or for unnecessarily fid- 
getting. Nervousness and irritability of temper are noticeable. Upon 
little or no provocation the child begins to cry. The muscles in 
various parts of the body later begin to twitch and contract, the face 
making ludicrous grimaces. These movements are entirely involun- 
tary, and if the examiner fixes the child's attention, these irregular 
movements are exaggerated. In the early stages the body move- 
ments may be slight and are best felt when the child's hands are placed 
within those of the examiner and the arms put on a slight tension. 
The tongue also when closely observed shows the twitching movements 
quite early in the disease. During sleep the movements cease. Fol- 
lowing a severe fright or chastisement chorea may suddenly develop 
with well-marked symptoms. Aggravated cases or those under no 
control are often pitiably affected; the child cannot dress or feed itself; 
sleep is disturbed; speech is altered and may be so changed as to be 
unintelligible. Pseudoparalysis due to muscular weakness may 
occur but the extremity is never completely at rest for any length of 
time. On the other hand, a case recently under our observation in 
the Post-graduate Hospital had such marked jactations, that she 
had to be fastened in bed and fed by gavage until relief of symptoms 
was obtained by medication. 

Hemichorea, in which the movements are confined to one side, is 
sometimes seen, and in these cases sensation is somewhat impaired on 
the same side. 

There is no elevation of temperature, unless the case is compli- 
cated with rheumatism or endocarditis. It is not uncommon to find 
a mitral regurgitant murmur develop during the attack. Sometimes, 
in fact, it may precede it. Functional or anemic murmurs are heard 
in prolonged cases. 



GENERAL NERVOUS DISEASES. 513 

Course and Prognosis. — Chorea is in itself almost never fatal. 
Uncomplicated cases tend to recover in from one to several months. 
Ten weeks is the duration in the average case. Relapses are frequent. 

Diagnosis. — This is, as a rule, quite simple, resting upon the 
characteristic muscular m^ovements and especially the abnormal 
movements of the tongue. Imitative choreic movements are dis- 
tinguished by their short duration, while in hysterical chorea the 
harmonious character of the movements and other hysterical phe- 
nomena serve to distinguish the neurosis. Sachs calls attention to the 
fact that choreic movements may be associated with infantile cerebral 
palsies and must be distinguished from true chorea. Spasticity and 
the increased reflexes should here put the examiner on the right track. 

Complications. — Acute or subacute rheumatism, and heart disease 
are the most frequent complications. 

Treatment. — The treatment differs for the mild and severe cases. 

Mild Cases. — Rest is the first and most important measure. With- 
out it all treatment is unsatisfactory. The child should be immedi- 
ately removed from school. By rest is here meant avoidance of all 
mental excitement or effort; physical rest is obtained by putting the 
child to bed in a well-ventilated room, and keeping it there until the 
coarser movements cease, then the child may be allowed up for a half- 
hour in the same room, and this allowance increased from time to 
time if good progress is made. Toys which require no effort on the 
part of the child are allowed, while reading and singing to the patient 
by the attendant serves to shorten the enforced rest. Visitors and 
the other members of the family are to be excluded. The diet is to 
be carefully supervised. Milk alone for a few days and later cereals 
and vegetables, eggs and butter are allowed. Alcohol sponge baths 
or brine baths for their tonic effect may be given daily. Arsenic in the 
form of Fowler's solution is given as an adjuvant, but should not be 
depended upon to cure the patient without the rest treatment, as it is 
far from being a specific. Begin with three drops three times a day 
for a five-year-old child and increase gradually by one drop up to 
thirty drops daily. The arsenic should be administered after meals, 
well diluted in some alkaline water. It must be stopped if there is 
any nausea or puffiness of the eye-lids. In rheumatic cases novaspirin 
or the salicjdate of soda may be given in conjunction with the above 
treatment. 

Severe Cases. — The rest cure is imperative. A padded bed is 

sometimes necessary. The movements should be quickly controlled 

by doses of the bromids with chloral per os or per rectum, and then 

the arsenic treatment may be begun. If the chloral and bromids are 

23 '^ 



514 DISEASES OF CHILDREN. 

not sufficient to control the jactations, a hypodermatic dose of hyos- 
cin hydrobromate grains 2^^o for a five-year-old child will do so. This 
should not be used if there is any heart involvement. Veronal, grains 
3, at night will promote sleep if there is insomnia. Feeding through 
a tube must occasionally be practised. It is best to order a certain 
fixed amount of nourishment to be taken or fed during the day. 

Convalescence. — School duties should be abandoned for some 
months. Life in the country, at the seaside, or in a suburban town 
is advisable. Baths, iron tonics, and nutritious diet, including the 
fats and meats, are now indicated, for profound anemias are often con- 
current with chorea and lead to relapses unless corrected. School 
life must not be resumed until such time as the possibility of a recur- 
rence is well past. 

Forms of Chorea. — Choreiform affections or movements are prac- 
tically synonymous with habit-spasms and tics. (See page 525.) 
Huntington's chorea or hereditary chorea is a rare disease of a chronic 
nature and occurs in later life. 

Chorea insaniens is a fatal form, which may be due to a bacter- 
emia. Chorea major is a hysterical chorea under which are included 
several groups described mainly by German writers, for example 
chorea electrica. 

Hysteria. 

True hysteria is a rare disease of early life, and is usually seen in 
children of the school age, especially in girls at puberty. 

Etiology. — Heredity is an important factor, for if one or both 
parents are neurotic there is likely to be little or no control over the 
offspring; they are indulged in every whim, and too much attention 
is paid to minor ailments, and the imitative disposition of the child 
is often the precursor of real trouble. Children in institutions and 
asylums who receive only little personal attention from their superiors 
are often the victims of hysteria. Morbid sensations and psychical 
phenomena, such as fear, are productive of attacks. 

Symptomatology. — The attacks do not present any great varia- 
tion from those seen in adults. The tendon reflexes are not so often 
found exaggerated and disturbances of sensation are not commonly 
observed. It would be impossile to describe a typical case of hysteria, 
as certain groups of symptoms are in evidence in one case and entirely 
absent in another. The symptoms are traceable to defects in the 
various body functions, symptoms, and organs. 

Sachs classifies the symptoms into three groups — psychic, motor, 
and sensory manifestations connected with vasomotor disturbances. 



GENERAL NERVOUS DISEASES. 515 

Under the first group are the weak-minded children with a per- 
verse will. Hysterical mania may manifest itself if the child's wish is 
opposed, following a sudden fright or even a fit of anger. Alternate 
laughing and crying with kicking or tearing of objects and clothes 
occur, while the disturbance is made worse by attempts to console or 
sympathize. Hysteroepilepsy, while undoubtedly extremely rare in 
children, is of greater importance than some of the other hysterical 
manifestations. These children have a vicious family history, in- 
cluding alcoholism, insanity, etc. The attacks must be studied and 
epilepsy excluded after repeated observations. In hystero-epilepsy 
there is no aura. The bladder and rectal functions are not disturbed, 
the attacks are of longer duration, there is no complete loss of con- 
sciousness, personal injury is rare, and the movements themselves are 
tonic, exaggerated, and often purposeful. 

A great variety of hysterical manifestations may be seen: those 
involving only the lower extremity or the head and neck alone. The 
esophageal spasm is not rare in girls at puberty (globus hystericus). 

Sometimes paralysis follows the jactations or occurs alone as a 
hysterical manifestation. Again, only certain functions may be 
paralyzed. Hysterical aphonia is not uncommon, especially in insti- 
tutions and asylums. They disappear quite suddenly when confidence 
is established, and local examination reveals a normal laryngoscopic 
picture. Any part or portion of the body may be affected. The 
regional paralysis is, moreover, usually associated with regional anes- 
thesia. The condition of the reflexes which are not exaggerated and 
the absence of spasticity in the muscles and the unaltered electrical 
reaction serve to differentiate it from the true forms. Spasmodic 
conditions, such as hiccough, dysphagia, anorexia, and vomiting, some- 
times occur and may be extremely troublesome. Spasmodic cough 
and purposeless screaming are especially seen in young girls. Hyper- 
esthesia and anesthesia are not so commonly observed as in adults, 
but when present are apt to distort the diagnosis if the physician is not 
on his guard. Disturbances of vision especially must be kept in 
mind in this relation. Organic lesions, however, should be carefully 
excluded before a diagnosis of hysteria is made. 

Prognosis. — This is better in children than in adults. Relapses 
are common if control is not absolute. 

Treatment. — The acute attack may often be interrupted in child- 
ren in the ordinary case by the use of the aromatic spirits of ammonia, 
not too well diluted, or by giving apomorphin in emetic doses. Cold 
douches, when unexpectedly applied to the face and chest may arrest the 
attack. In intractable cases the rest treatment should be faithfully tried. 



516 DISEASES OF CHILDREN, 

If this is not effective a change of environment is then most important. 
The neurotic parent influences the child not only through the inherently 
weak nervous system, but by improper training and defective 
example. Sometimes it is necessary to send these children to special 
schools whose principals have made a study of neurotic children. 
Improvement in general physique is always to be aimed at and is at- 
tained by aerotherapy and nutritious plain food. The dietary should 
be supervised and a special list prepared for the needs of the particular 
child. 

The suggestive influence of the physician who will exert his force 
of character and thus establish confidence can be made extremely 
powerful in its effect, and often produce a cure alone. Baths and 
douches have a distinctly favorable influence. The electrical currents 
are sometimes useful for their moral effect. Medicinal measures are 
rarely necessary if the above plan is feasible and strictly adhered to. 

Epilepsy. 

Epilepsy is a disease often occurring in early life, and character- 
ized by seizures which vary in their intensity, affecting only a portion 
of the body, or they are generalized. 

Etiology. — The children of neurotic parents, those who have 
themselves been afflicted with epilepsy, hysteria, chorea, and similar 
nervous diseases, may fall victims to this disease. To these may be 
added syphilis and alcoholism. Traumatism during or after birth and 
maldevelopment of the brain as a result of acute infective processes 
may later lead to epileptic seizures. 

Among the exciting causes the intestinal toxemias, visual defects 
and obstructive growths in the respiratory tract, such as adenoids and 
polypi, may be mentioned. 

Symptomatology. Petit Mai. — In this form there may at inter- 
vals occur momentary periods of unconsciousness. The child may 
suddenly cease playing or speaking and stare into vacancy. The 
parents may bring the child to the physician complaining of its ^^ faint- 
ing attacks." If questioned, the child has no recollection or knowl- 
edge of these periods. If seen at the time of an attack, the pupils of 
the eyes may be seen to suddenly dilate and the face turn pale. Occa- 
sionally there is a period of drowsiness or the child seems dazed and is 
not willing to immediately resume its former occupation. 

Grand Mai. — There is no sharp limit between the mild and the 
severe forms. Grand mal is spoken of if there is an aura, a period of 
unconsciousness, a convulsion, and the involuntary passage of urine 



GENERAL NERVOUS DISEASES. 517 

and feces. It should be recollected that young children may not have 
an aura or may be incapable of interpreting it. Intelligent parents 
may sometimes foresee a coming attack by noting a change in the child's 
disposition or by observing certain unusual bodily movements. The 
sensation may be felt in the different situations, as the stomach, the 
eyes, or noises in the ears. 

The child suddenly falls into unconsciousness and a convulsive 
seizure takes place simulating the ordinary eclamptic seizures de- 
scribed on page 510. Sometimes an initial cry precedes the fall. The 
dilated pupils do not react to light, the tongue may be bitten, and blood- 
stained saliva may appear at the mouth, although this is not usual in 
childhood. After a few minutes the spasm relaxes and the patient is 
found to have involuntarily passed his urine or even emptied the 
rectum. Following the return to consciousness, the patient is in a 
semicomatose or stupid condition, complains of headache, and often 
drops into a restless sleep. Nocturnal attacks may be discovered 
only by the bitten tongue or drowsiness on the succeeding day. The 
''epileptic voice sign" of Clark and Scripture may excite suspicion in 
the medical attendant. It is described as a monotonous voice, the 
melody proceeding by even steps and occurs in this disease alone. 

Diagnosis. — Hysteria is differentiated from epilepsy by the ab- 
sence of entire loss of consciouneess, the stage of excitation with laugh- 
ing and crying, and by the absence of dilated pupils and involuntary 
urination and defecation. Tumors of the brain may affect localized 
regions; they may have peculiarities of gait and changes in the fundus 
of the eye. 

Prognosis. — The gravity is determined to a great extent by the 
age. The earlier the seizures appear the poorer the prognosis. Fre- 
quent recurrences of well-marked attacks are less hopeful and may be 
followed by feeble-mindedness. 

Treatment. — During the attack the child should be placed in bed 
and guarded against personal injury. Little or no food should be 
offered after the attack until the period of drowsiness is past. The 
diagnosis once established, stringent prophylactic measures should 
be instituted to prevent recurrences. A life in a quiet country dis- 
trict with an unusual amount of sleep and little mental exercise is dis- 
tinctly beneficial. A diet consisting of simple food (coffee and tea 
being absolutely excluded), with plenty of vegetables and fresh fruits 
to insure daily bowel activity, is required. For the children of the 
poor, life in the epileptic colonies, where the children conform to a 
certain routine adds much to their chances of improvement. 

The bromids when administered in divided doses, five grains for 



518 DISEASES OF CHILDREN. > 

a five-year-old child three or four times a day, while not curative, serve 
to reduce the number of attacks. When the latter occur at night only^ 
it is best to administer one large dose, about twenty grains, at bedtime. 
This drug should be given to the point of toleration and resumed after 
a period of rest. 

Headaches. 

Headache is a symptom deserving of especial attention since it 
may be symptomatic of many functional or even organic disorders. 

Etiology. — It most frequently results among children from gastric 
o'r intestinal disturbances and from eye-strain. Anemic children who 
have been improperly fed and who are forced into competition with 
their schoolmates often suffer from toxic headaches. If the child 
remains in badly ventilated or superheated rooms frontal headaches 
frequently result. The cause may be more obscure and may be 
found to result directly or indirectly from adenoids, ear disease, neph- 
ritis, cardiac disease, and malarial poisoning. Young girls at the 
beginning of the menstrual period, especially if they are neurasthenic, 
may complain of frequent headaches. Many of the acute infectious 
diseases are preceded by cephalgia as a prodromal symptom. Men- 
ingitis and tumors of the brain cause persistent headaches which are 
referred to one area. 

Migraine or sick headache occurs in older children. It is usually 
unilateral in character and preceded by nausea and vomiting and dis- 
turbances of vision. 

Diagnosis. — The diagnosis depends upon a careful physical ex- 
amination to exclude organic disease, and in obscure cases of this 
type lumbar puncture, the opthalmoscope and the tuberculin tests 
may be necessary. Functional headaches when dependent upon 
intestinal derangements are accompanied by a coated tongue, a fetid 
breath, and constipation. Those due to anemia and general asthenia 
exhibit pallor of the mucous membranes, lassitude, and depression. In 
these cases a blood examination, at least the Talquist hemoglobin 
estimation, should be made. Headaches due to visual errors begin 
or are intensified at the end of the school day or whenever the eyes 
have been overtaxed. An examination with the test cards (see p. 598) 
should be made as a matter of routine, as a more detailed ocular 
examination may then disclose astigmatism or other refractive errors. 

The diagnosis of migraine depends upon the periodic unilateral 
attacks and the accompanying nausea and eye disturbances. 

Treatment. — This is directly dependent upon the cause. When 
the headache is the result of digestive errors acute attacks may be 



GENERAL NERVOUS DISEASES. 519 

relieved by clearing out the intestinal tract and prescribing a proper 
dietary which is to be strictly followed. Anemic headaches are cured 
by life in the open air or at least an abundance of fresh air and sun- 
shine in the rooms which the child occupies. Reducing the number 
of study hours and prohibiting special studies after school hours may 
alone be sufficient. Obstructions in the respiratory tract and errors 
of refraction must be removed before any progress can be made. 

A child suffering with migraine should be put to bed in a quiet 
dark room, during the attack, and analgesics, as phenacetin combined 
with caffein or the bromids, may be given. A hot-water bag or light 
massage over the forehead and temporal regions may be agreeable. 
Future attacks must be prevented by strict regulation of the child's 
life and diet. 

Insomnia. 

This symptom which occurs in infanc}^ and childhood generally 
results from some functional derangement which can usually be 
removed when once recognized. 

The infant and child are dependent upon a sufficient amount of 
sleep to promote healthy growth. That it cannot or does not spend 
sufficient hours in sleep may be due to acute physical discomfort or 
from a perversion of its natural habits resulting from mismanagement 
on the part of its attendants. 

The following table will give a general idea of the daily amount 
of sleep required in early life: 

Healthy new-born, 20 hours, minimum 16 hours. 

Six months, 16 hours (2 naps). 

One to three years, 12 hours (and one nap). 

Three to six years, 12-10 hours. 

Six to ten years, 10-8 hours. 

When the infant is unable to approximate the normal amount of 
sleep a careful examination of its mode of life should be made followed 
by a systematic physical examination. Among the more frequent 
causes of sleeplessness are digestive disturbances, undue excitement, 
bad hygienic conditions, and localized pain. Physical examination 
may show that the child is suffering from an otitis, skin lesions, en- 
larged tonsils, adenoids, rachitis, extreme anemia, or the disease may 
be organic, such as meningitis or incipient disease of the brain or spinal 
cord. 



520 



DISEASES OF CHILDREN. 



Treatment. — When the cause is found efforts should be made to 
remove or correct it before any other measures are undertaken. A 
careful regulation must be made of the child's daily life, not omitting 
what may seem to be minor influences bearing upon its sleeplessness. 
A well-ventilated, cool, darkened room should be provided, which the 
infant or child should occupy alone; the bed clothing should be light 
and not too warm. The evening meal must be simple, not containing 
too much liquids. Reading of exciting stories to children should be 
prohibited. These changes with an outdoor life are often sufficient 
to correct insomnia. 

If a high temperature is the cause of the insomnia, baths or spong- 
ing with alcohol will often promote sleep. If temporarily any of the 
hypnotics are necessary, the bromids, in doses of one and a half grains 
for each year of age, or one grain of veronal for a two-year-old child 
will produce the desired effect. The bromids combined with chloral 
hydrate are effective in older neurotic children, especially if they 
also have night terrors. 



Payor Nocturnus. 



{Night Terrors.) 

This condition occurs in children who have in some manner unduly 
excited their nervous system. They may or may not be the children of 
neurotic parents. Children from the third to the eighth year are more 
commonly subject to night terrors. In our experience the condition 
appears with the greatest frequency at the beginning of school life 
when unaccustomed responsibilities must suddenly be assumed. The 
reading of unnatural stories so often practised by nurses or unusual 
and grotesque sights, as in the circus, may induce an attack. A 
heavy meal just before retiring may also be a cause. 

The children awake suddenly, usually before the midnight hour, 
and cry out, exhibiting signs of fright or terror. They are soothed 
with difficulty and can give no explanation of their sudden awakening 
or dream. If questioned in the morning they remember nothing of 
the occurrence. The terrors may repeat themselves several times in 
a week, but they seldom occur twice in the same night. When the 
cause is removed the recurrences become more infrequent and finally 
disappear altogether. 

Treatment. — Every effort should be made to decrease the ner- 
vous excitability of the child by prohibiting school work at all for a 
time or decreasing the number of school hours. At home no supple- 



GENERAL NERVOUS DISEASES. 



521 



mentary teaching should be allowed and association with older minds 
not encouraged. A healthy amount of physical tire, rather than 
mental strain should be the desideratum. The evening meal particu- 
larly should consist of Kght and easily digested articles, and should 
be eaten at least an hour before retiring. If these measures are 
carried out it will rarely be necessary to give bromids or hypnotics. 

Tetany. 

(TetaniUa; Arthrogryposis.) 

Tetany is a neurotic disorder characterized by intermittent 
or constant tonic spasms of the muscles of the upper and lower 
extremities. 

Etiology. — The disorder is dependent upon the absorption of 
toxic products which readily affect the highly sensitive nervous 
system of early life. It occurs most frequently from the sixth month 




Fig. 133. — Tetany, with characteristic positions of hands and feet. 



to the end of the second year. We would give rachitis the first place 
in the role of etiologic factors, and the conditions which may produce 
this disease may also produce tetany. This is further borne out 
by the fact that convulsions and laryngismus stridulus frequently 
occur in those subject to tetany. It also results from intestinal 
or peripheral irritation and may follow exhausting diseases or 
secondary pneumonias. 

Symptomatology. — The condition begins without any warning in 
infancy, although older children sometimes complain or give evidence 



522 



DISEASES OF CHILDREN. 



of an itching or tingling sensation. Attention is generally called to the 
condition by the muscular contractions of the hands and feet. A 
close examination will show that the arms are held quite closely to the 
chest, the forearms being partly flexed on the arms and the hand 
flexed at the wrist, while the fingers may either be tightly closed over 
the inverted thumb on the palm, simulating the driving position, or 
they may be hyperextended and held closely together like the obstet- 




FiG. 134. — Tetany in the new-born. 



ric hand. In the lower extremities the thighs may be drawn up onto 
the abdomen and the legs flexed on the thighs; some degree of adduc- 
tion of the thighs is generally present. The foot itself is extended or 
hyperextended, and the toes are flexed. The position of talipes equino- 
varus being often assumed. We have also noted spasticity of the 
erector-spinae group of muscles, so that the child could be raised by 
the head retaining an erect posture. The child's expression is one of 
discomfort. Pain is elicited if attempts are made to replace the ex- 
tremities in their natural positions. There is rarely any temperature 
which can be attributed to the condition itself and the mentality is 



GENERAL NERVOUS DISEASES. 523 

not affected. After a variable time, sometimes a few days or it may be 
weeks, the contractures intermit and the so-called latent period may be 
entered into, in which there is weakness and some slight spasticity of 
the affected muscle groups, or the symptoms may never return. In 
this disease certain phenomena may be elicited which are distinctly 
helpful in making or confirming a diagnosis. 

Trousseau^s symptom can be produced in the latent period by 
pressing upon the main nerves and arteries of the extremities. In this 
way a characteristic paroxysm can be produced which ceases when the 
pressure is removed. 

ErVs symptom is dependent upon the increased electrical excita- 
bility in the peripheral nerves, muscular contractions being produced 
even by weak currents. 

Chvostek's symptom is a facial phenomenon which is of value if 
obtained in conjunction with the others and is elicited by pressing the 
finger or any other blunt object over the facial nerve when contrac- 
tions immediately occur. 

Differential Diagnosis. — From tetanus it may be distinguished 
by the absence of trismus which is an early symptom, by the lack of 
fever, by the intermittent attacks, and the ability to elicit Trousseau's, 
Erb's and Chvostek's signs. Cerebrospinal meningitis is distinguished 
by the presence of high irregular temperature, cerebral signs, and by 
lumbar puncture. 

Prognosis. — The prognosis is mainly dependent upon the under- 
lying cause. In itself it rarely endangers life except by predisposing 
to convulsive seizures. 

Treatment. — The underlying condition must be carefully sought 
for and treatment immediately directed toward its removal. It is a 
safe rule to thoroughly empty the boAvels by the use of a large dose of 
castor oil or calomel. An enema may be given for immediate relief. 
The stools should be kept for the physician's examination, as he may 
therein find the source of the peripheral irritation, such as badly digested 
food or intestinal parasites. Baths at a temperature of 110° F. may 
be given two or three times during the day for their relaxing effect. 
In severe cases a mixture of chloral hydrate and the bromid of soda 
can be injected into the rectum. In the latent period dietetic mea^ 
ures should be coupled with most favorable hygienic conditions. The 
food ordered must be such as to overcome the rachitic manifestations 
if present (see p. 457), or produce an increase in weight if the neuro- 
sis has resulted from an exhausting disease. 



524 DISEASES OF CHILDREN. 

Myotonia Congenita. 

(Thomsen^s Disease.) 

Myotonia congenita is a rare disease, mainly hereditary, charac- 
terized by a sudden rigidity of certain muscle groups when a voluntary 
movement is attempted. 

Etiology. — The disease may occur early in childhood, but the 
greatest number of cases are seen between the fifteenth and twenty- 
fifth year. Thomson believes it to be a hereditary disease; five 
generations in his own family having been so afflicted. Inclement, 
cold weather and emotional states may bring on the attacks. 

Symptomatology. — The muscular contractions develop when the 
patient attempts some voluntary act, as rising from bed or from a 
chair. The muscular spasm prevents the completion of this effort, and 
repeated attempts are necessary before it is accomplished. These 
inhibited efforts in a child otherwise well developed are striking 
enough to fix the diagnosis. If a sharp blow is given over a muscle, 
a tonic contraction occurs which persists for some time. Erb has 
shown that the muscles react peculiarly to electrical stimuli. This 
''myotonic reaction," as he calls it, is a valuable confirmatory sign. 
Faradic currents stimulate the muscles, producing wavy, rhythmical 
long-continued contractions. The same effect may be produced by 
the galvanic current. 

Diagnosis. — The disease is distinguished from tetany by the con- 
tractions produced by mechanical stimulation and by the peculiar 
electrical reaction (Erb's myotonic reaction). Furthermore, there 
is no increase in mechanical excitability by pressure over the nerve 
or vessel trunks as in tetany. Congenital paramyotonia (Eulen- 
berg's modification) may be differentiated by the absence of the myo- 
tonic electric reaction and also of any increase in the mechanical 
excitability. 

Treatment. — Thomson noted that the symptoms appeared less 
often the greater the muscular activity of the patient; he therefore 
advised a life which would necessitate a constant use of the muscles. 

Paramyoclonus Multiplex. 

This disease, although very rare in early life, is mentioned here 
mainly for the purposes of differential diagnosis. It is character- 
ized by the production of repeated momentary clonic spasms affecting 
a certain muscle or groups of muscles which are usually symmetrically 
involved. The muscles of the face are rarely involved. A sHght tre- 



GENERAL NERVOUS DISEASES. 



525 



mor of the muscles may be observed between the attacks which usually 
follow some strong emotional excitement or physical effort. 

The myotonic reaction is rarely increased and no change in elec- 
trical excitability is noticed. 

Treatment. — We are almost powerless to effect a cure in this dis- 
ease, although amelioration of the symptoms is possible by the use of 
sedative baths, mild gymnastic exercises, and a life free from 
excitement. 

Angioneurotic Edema. 

(Acute Circumscribed Edema.) 

This is a vasomotor disturbance, trophic in origin, characterized 
by attacks of circumscribed edematous areas on the body. 

Gastrointestinal intoxication is the most frequent cause in chil- 
dren, although it sometimes appears without any discoverable reason. 
The edema may be well-marked a few hours after its inception and may 
just as suddenly disappear, only to reappear in some other portion of 
the body. There are no marked constitutional symptoms, the chil- 
dren simply complaining of the itching or the discomfort caused by 
the edema when it affects, for example, the face. 

In a recent case seen by one of us there were unquestionable 
signs of edema of the lungs, which appeared suddenly, and cleared up 
within forty-eight hours. The area affected is raised, pale in the 
center, with an irregular bluish-red margin, differing from the other 
edemas in that it does not pit on pressure. Fatal cases have been re- 
ported in which the larynx and pharynx were affected. 

Treatment. — Special treatment during the attack is hardly neces- 
sary. Compresses wrung out of warm boric acid solution are soothing 
to the patient. A sahne purge should be given and future attacks 
inhibited by scrupulous attention to the dietary. 

Tics. 

A tic is the unconscious activity of a group of voluntary muscles 
resembhng a purposeful movement, its frequent repetition classing it 
as a habit. 

They occur most frequently in children from the fifth to the 
fourteenth year of life. An underlying neurotic element can usually 
be found in the patient or he has been trained under attendants who 
by their management have not developed his self-control. These 
neurasthenic children may easily develop a tic from some primary 



526 



DISEASES OF CHILDREN. 



source of irritation, as foreign objects or growths in the air passages or 
eyes, skin diseases, as eczema, phimosis, or even chorea. They may 
arise from emotional disturbances or as a result of imitation as pointed 
out by Scripture in children of unstable and willful disposition. The 
most common tic is the one involving the muscles about the eye in 
which the child rapidly winks the eye-lid several times in succession. 
This occurs at short intervals during the day. Not unlike these in 
motor characteristics are the tics affecting the face, scalp, ears, tongue, 
neck, and extremities. When tics are accompanied by mental 
disturbances, a child otherwise rational may repeat words or phrases 
of an obscene character without provocation or regard to the time and 
place. This is known as coprolalia. 

Differential Diagnosis. — Tics may be distinguished from chorea 
by the purposive, systematic nature of the movements which occur 
at intervals. The spasms of paramyoclonus multiplex affect only a 
certain muscle and are not controlled by fixing the attention. Habit 
spasms resemble normal movements, but differ from them in that 
they are unnecessary. They are unlike tics in that they are not con- 
vulsive in type. 

Stuttering and Stammering (Hyperphonia). — In this connection 
another class of tics forming a large part of the speech defects of child- 
hood may be considered. Scripture defines hyperphonia as a psycho- 
motor neurosis or a mental tic or habit over which the patient has no 
control and which is the result of a compulsive idea connected with 
speaking. A neurotic child may acquire the habit by imitating others 
or he may have some defect connected with his respiratory apparatus. 

The symptoms have been divided into spasms and hypertonicity, 
affecting the respiratory, laryngeal, and articulatory muscles; to these 
are sometimes added facial and bodily tics. 

Treatment. — A careful physical examination, including the special 
organs, and an inquiry into the details of the child's life should be made 
in every case. An underlying and neglected cause may be found in 
refractive errors, abnormalities in the nose, ears, or teeth. Peripheral 
irritation from any source must be removed; while this is not curative, 
it is conducive to a more rapid recovery and prevents recurrences. 
The physical condition of the child should be improved by nutritious 
food, tonic baths, ample amount of sleep, and a routine life under judi- 
cious discipline. A change of environment will often make the spe- 
cial treatment much more effective. Fowler's solution may often 
be given with benefit. In a number of our cases the method advocated 
by Scripture was remarkably effective. It depends upon the volun- 
tary imitation of his own act by which the child is trained to a con- 



GENERAL NERVOUS DISEASES. 527 

scious performance of the tic. In this way he is encouraged and en- 
abled finally to inhibit the act. The child looks into a mirror and is 
directed to imitate five times in succession his own tic when it appears. 
At first the imitation is a poor one, but improves with practice, until 
finally complete control is obtained. 

Scripture's method for stuttering and stammering consists in 
introducing melody into the monotone voice of the stutterer. The 
child is directed to repeatedly sing a line of some familiar song; he 
is then taught to speak a sentence in the same sing-song fashion. 
In this way the monotone voice is finally abandoned and cadences 
and inflections are introduced. The '^ melody cure" is founded 
upon the fact that a stutterer never stutters when he sings. This 
simple treatment is elaborated by encouraging the child in forms of 
elocution and graceful mannerisms. 

Finally, in some cases it is also necessary to distract the mind 
when the patient starts to speak; this is done by teaching him to beat 
time in a quick, vigorous manner as he starts to speak or to set him- 
self off by repeating one, two, and starting off to speak on three. These 
lessons are given at first three times a week for half-hour periods, 
the time and interval being lessened as progress is made. 



CHAPTER XXXVII. 
DISEASES OF THE PERIPHERAL NERVES. 

Multiple Neuritis. 

Definition. — An inflammation of the peripheral nerves, in some of 
which there is a tendency to acute degenerative changes. It may 
affect several nerves, usually 'symmetrically, or it may be general. 

Etiology. — Bacteria or at least bacterial toxins in all probability 
cause the disease. The infectious diseases, especially measles, malaria, 
influenza, typhoid, and tuberculosis, may be followed by a polyneuritis, 
but it is a rare complication, with the exception of diphtheria. Some- 
times exposure or cold and rarely alcohol, arsenic, or lead cause the 
disease. Alcohol must be considered as a factor in treating the chil- 
dren of our foreign population. 

Pathology. — There is an inflammation of the affected nerve, inter- 
stitial or parenchymatous in character, followed by more or less com- 
plete degeneration of the fibers. The appearance of the nerve at 
first is that of an acute inflammatory nature, with swelling, hyperemia, 
and minute hemorrhages in the nerve sheaths. Later degenerative 
changes in the nerve fibers only are seen. The muscles undergo paren- 
chymatous or even interstitial changes. 

Symptomatology. — The onset may be sudden, with a chill or a 
convulsion and fever; as a rule, however, it is gradual. The mother 
may notice that the child is unable to properly support itself on its 
feet; if forced attempts to walk are made the child stumbles or sinks 
to the floor. After a few days or sometimes within a few hours there 
is intense pain on handling. The child cries when approached, fearing 
the pain of motion. Occasionally the sensitiveness along the course of 
the nerve may be elicited. Paralysis now follows the muscular weak- 
ness and it progresses symmetrically. The child may continually 
moan or cry out with the pain, but does not refuse its food. Foot-drop 
and wrist-drop develop, and the muscular contractions may cause de- 
formities. Tendon reflexes are abolished altogether, or at least dimin- 
ished, and the reaction to the galvanic current is slow. Muscular 
atrophy develops, but is not marked. 

Diagnosis. — The history of an antecedent disease or a distinct 
casual factor, as alcohol, may be suggestive when pain and paralysis 
ensue. The association of motor and sensory symptoms or paralysis 

528 



DISEASES OF THE PERIPHERAL NERVES. 529 

along anatomical lines and the changed electrical reaction should 
cause no confusion. When there is lordosis present from involvement 
of the muscles of the back, it may be mistaken for Pott's disease, but 
the deformity is not angular and the position assumed will differen- 
tiate it. 

Course and Prognosis. — Cases with sudden onset in which the 
electrical reaction is rapidly changed and in which atrophy occurs 
early are not favorable for recovery. The average case begins to im- 
prove after the first month, recovery generally being complete in 
three months. The sensory symptoms clear up first, then the reflexes 
are obtained. In some cases the paralysis may be permanent. In- 
volvement of certain nerves, as the vagus, or intercurrent diseases may 
bring on a fatal issue. 

Treatment. — If the disease is due to a drug or alcohol poisoning 
this must be stopped at once and eliminatives given. An initial 
dose of calomel is always in order. The child should be placed in a 
comfortable attitude, the limbs encased in cotton wool and lying on a 
down pillow. The pain should be controlled by analgesics, such as 
the bromids, phenacetin, or even codein if necessary for one or two 
doses. Rest and hot applications during the onset, and later massage 
and vibratory treatment as it is given in infantile spinal paralysis is 
effective. If the extremities are kept in a proper position while the 
disease is in progress, deformities are not likely to result and ortho- 
pedic appliances will not be necessary. 

Diphtheritic Paralysis. — This is a form of multiple neuritis worthy 
of special note. It is the most common cause in early life and affects 
for the most part only one region, this is the palate. We do not meet 
with the condition as frequently since antitoxin has come into general 
use. It is less likely to follow if the diphtheria has been recognized 
early and the child injected with the serum at once. We have, how- 
ever, seen a fatal issue in cases that were considered extremely benign 
and in which the prognosis was excellent. Children under two years 
of age are rarely affected. Malignant laryngeal cases are more sus- 
ceptible of involvement. It sometimes occurs during the active process, 
but usual!}' it appears in the third or fourth week of convalescence. 

Symptomatology. — Inability to swallow well with regurgitation 
of fluids through the nose or a peculiar nasal twang in the voice may 
first attract attention. The eyes may next show the paralysis, and 
if this is more extensive the lower extremities are affected, followed 
by similar changes in the arms and the muscles of the trunk. Ex- 
amination of the throat will easily disclose a paresis of the pharynx 
and soft palate; it is relaxed, flabby, and does not take part in the 

34 



530 DISEASES OF CHILDREN. 

acts of speaking or swallowing. Closer examination of the eyes shows 
weakness of the ciliary muscles, the pupil reacting sluggishly and 
causing defective vision. When the external ocular muscles are 
paralyzed, strabismus results. 

Following the laryngeal cases the loss of voice is particularly 
marked and persistent, and if the paralysis occurs during the intubation 
period difficulty may be experienced in keeping the tube in place. 
Recovery is the general rule; fatal cases resulting from the involve- 
ment of the vagus, or from aspiration pneumonia when the epiglottis 
is involved. The course depends upon the extent of the paralysis and 
the regional involvement. The average case requires two months for 
recovery. The muscles of the eyes and the palate recover much more 
quickly than the muscles of the extremities. Weakness of the back 
and inability to properly support the head, with the loss of the reflexes, 
may persist for months. 

Treatment. — Rest in bed and close observation should be insisted 
upon when the first symptoms of paralysis appear. The manage- 
ment will depend upon the extent of the regional involvement. Cer- 
tain cases in which there is only aphonia or partial paralysis of the 
palate will require no special treatment, but the heart in all cases 
should be carefully watched and stimulation given if necessary. 
Strychnin nitrate has served us the best for this purpose. Where 
deglutition is interfered with gavage may be necessary, although care- 
ful feeding from the spoon in small quantities can usually be success- 
fully practised. The food should be as nourishing as possible, and 
the appetite and general health are improved by placing the patient 
as much as possible in the open air. 

Facial Paralysis. 

{BelVs Palsy.) 

Paralysis of the seventh nerve is not an infrequent affection in 
infants and children. 

Etiology. — During infancy it may occur as a result of pressure 
upon the nerve with the forceps or in contracted pelves from impac- 
tion upon the head. Caries of the petrous portion of the temporal 
bone accompanied with inflammatory exudates may cause paralysis 
by pressure on the nerve. 

In children over three years of age sudden exposure to cold, 
which in all probability induces an infection, is the commonest cause. 
It may also accompany or be produced by traumatism within the skull, 
basilar forms of meningitis, polioencephalitis, and tumors of the brain. 



DISEASES OF THE PERIPHERAL NERVES. 



531 



We frequently see this paralysis following the radical mastoid op- 
eration in which the nerve may be temporarily injured or destroyed, 
usually as a result of incompetent surgery. 

Symptomatology. — Inspection of the child's face will show a 
droop at the mouth on the affected side and the natural folds in this 
region almost or quite disappear, while the angle of the mouth is 
drawn down. The child cannot close its eye, and if attempts are made 
to do so the eye-ball moves upward. It can only blow out the cheek 

on the unaffected side. The 
protruded tongue deviates to 
the unaffected side and food 
particles may lodge between 
the cheek and gums. Speech 
may be affected, while attempts 
at whistling or laughing accen- 
tuate the paralysis. 

Prognosis. — This is good 
for those cases due to sudden 
chilling. Pressure palsies at 
birth may recover in whole or 
in part. If due to destructive 
disease in the petrous portion 
of the temporal bone or to 
intracranial diseases, the prog- 
nosis is bad. Following oper- 
ative procedures the prognosis 
depends upon the amount of 
traumatism the nerve has sus- 
tained, and many of these cases slowly recover even after complete 
section. 

Treatment. — In the mild cases recovery will take place without 
any treatment. The galvanic current is used in the severer cases and 
in those which follow operative procedures in conjunction with mas- 
sage and mild vibratory treatments. As the power returns the child 
may be encouraged to exercise the muscles by imitating grimaces or 
blowing upon musical instruments. If a neglected otitis media is 
the cause, surgical procedures are indicated. 




Fig. 135. — Facial Paralysis. 



CHAPTER XXXVIII. 
DISEASES OF THE SPINAL CORD. 

Myelitis. 

Myelitis or inflammation of the spinal cord may be divided ac- 
cording to the course into an acute, a subacute, and a chronic form. 

Etiology. — It may result from injuries severe or even considered 
mild in character. It may follow the acute infectious fevers and septic 
processes anywhere in the body. 
It may extend or result from a 
meningitic process. It may also 
be caused by new growths in 
the spinal canal. Syphilis and 
Pott's disease, however, are the 
two causes which are most com- 
mon in children. 

Pathology. — The cord on 
section, in the affected areas, 
shows a congestion of its men- 
inges, while the cord itself has 
been changed to a soft pulpy 
mass. The white matter is with 
difficulty distinguished from the 
gray. Minute capillary hemor- 
rhages are found throughout the 
gray matter and the cells in the 
anterior horn show marked de- 
generative changes. The blood- 
vessels of the cord are dilated 
with proliferation of leukocytes, 
amalacious bodies, and degener- 
ated axis-cylinders. In the sub- 
acute or chronic forms some 
evidences of sclerosis may be 
found. 

Symptomatology. — In acute myelitis there is a sudden onset with 
a temperature which may rise to 104° F. as a result of the infective 
process. Painful areas may be elicited on pressure along the spine 
or the tenderness may be subjective. Clinical evidence will soon 

532 




Fig. 136. — Lumbar myelitis, showing con- 
tractures and deformities. 



DISEASES OF THE SPINAL CORD. 



533 



appear of functional disturbance of the cord and will vary with the 
intensity and localization of the process. The myelitis will affect 
motion and sensation and derange the functions of the bladder and 
rectum. Paraplegia results. Anesthesia will be present in the parts 
of the body supplied by the nerves which originate below the involved 
area. Thus there is loss of such sensory impulses as pain, touch, 
thermal and muscular sense. A hyperesthetic zone, due to the irrita- 
tion of the nerve fibers may be present above the anesthetic area. 
The reflexes are disturbed depending upon the area involved. 




Fig. 137. — Bed-sores in myelitis. 



Cervical lesions cause a paralysis in all four extremities. In 
the arms it will be flaccid in type, while in the lower extremities 
the palsy will be spastic in character. The whole body is anesthetic 
below the neck. In the dorsal region which is most commonly 
affected in children the upper extremities are not involved, while the 
lower become spastic. The patellar and plantar reflexes are increased 
and ankle clonus is present. Lumbar lesions produce a flaccid paraly- 
sis in the lower extremities which is later accompanied by some degree 
of atrophy. The urine dribbles away and the rectum is incontinent. 
The reflexes are lost and sensation is absent to a point above the lesion. 
Bed-sores, the result of trophic disturbances, cystitis, and infections 
of the urinary tract easily occur, and in fact may bring the case to a 



534 DISEASES OF CHILDREN. 

fatal issue. Contractures and deformities may result in the extremi- 
ties unless measures are taken for their prevention. 

Diagnosis. — The etiological factor, the sudden onset, the paralysis 
of a flaccid type above and spastic below, accompanied with anesthesia 
and derangements of the bladder and rectum should make the diag- 
nosis easy. 

Prognosis. — Lesions in the cervical region are the most danger- 
ous tn life. Myelitis in the dorsal and lumbar region may cause death 
from infective processes arising in the bladder, rectum, or from bed- 
sores. The younger the child, the more unfavorable the prognosis. 
Syphilitic cases, if the diagnosis is made easily, should give favorable 
results under specific treatment. 

Treatment. — Acute Stage. — Absolute rest in bed on an air mat- 
tress is essential. Ice bladders may be placed over the spine while 
the fever is active and for the relief of pain. The bowels are emptied 
by a brisk cathartic, and the bladder reheved by an attendant accus- 
tomed to surgical cleanliness. In syphilitic cases the mercurials with 
the iodids are given. If there is intolerance to these, the mercury 
may be given by inunction. If a specific infectious process can be dem- 
onstrated, such as streptococci, and isolated from the patient's own 
blood, treatment by vaccines may be tried. Bed-sores must be guarded 
against by scrupulous cleanliness, frequent change of position, and the 
daily application of alcohol or astringents. If they do develop they 
should be thoroughly cleansed and treated with stimulating antisep- 
tics, such as silver nitrate. 

After the subsidence of the acute symptoms, skilled massage 
may be employed in conjunction with warm tonic baths. Arrange- 
ments should be made so that the child can be taken out of doors on 
a roller bed or chair so that its nutrition may be preserved and its de- 
sire for food stimulated. 



Multiple Sclerosis. 

{Disseminated Sclerosis.) ' 

The disease may have its inception in, or it may be associated 
with any of the acute infectious diseases. 

Pathology. — Throughout the central nervous system patches of 
sclerosis are found. They may be more frequent in one area than 
in another, invading the brain, the pons, the medulla, the lateral and 
the posterior columns of the spinal cord, or even the spinal roots 
may be affected. Closer examination shows that the myelin sheaths 



DISEASES OF THE SPINAL CORD. 535 

of the nerve fibers are destroyed, although the axis-cylinders in the 
sclerotic areas do not suffer. 

Symptomatology. — At first there may be weakness of the upper 
and lower extremities accompanied with some trembling of the hands 
and the development of a spastic gait. This is followed by an inten- 
tion tremor which is quite characteristic of this disease, and which 
is accentuated by voluntary action on the part of the patient. It 
disappears when the extremity is at rest. Later in the disease the 
tremor may be so intense as to prevent the ordinary activities, as 
dressing or eating, etc. A speech defect now appears; it is slow, de- 
liberate, careful, with a tremulous character. It is spoken of as scan- 
ning speech. Nystagmus or oscillation of the eye-ball appears at this 
time and is especially marked when lateral movements are attempted. 
The pupils usually are contracted and reaction of accommodation to 
light is sluggish. The mental faculties become impaired, memory 
particularly is poor, and sudden emotional changes occur on the least 
provocation. The expression of the face becomes dull and stupid. 
A spastic form of paralysis, not very apparent at first, later becomes 
well-marked, producing a spastic gait. As the disease advances the 
tremor becomes so intense that walking is impossible, and finally 
the patient is bed-ridden. After a long and tedious course the disease 
finally ends fatally, the patient dying of some intercurrent disease. 

Treatment. — All that can be done for this incurable disease is to 
regulate the life of the patient so that an unusual amount of rest is 
secured and the muscles kept in good condition by baths, massage, 
vibratory treatment, and the galvanic current. Drugs do not in- 
fluence the disease, and if given at all they should be prescribed for 
symptoms as they arise. 

Hereditary Ataxia. 

(Friedreich's Ataxia.) 

This is a disease occurring in the members of the same family 
and characterized by an ataxia with a slow but progressive course. 

Etiology. — The disease is hereditary in character, passing often 
through several generations. The males or the females of a family 
inherit the disease. The spinal symptoms in some cases predominate, 
and in others the cerebellar are more in evidence. The spinal form 
occurs in the ages of four to seven, while the cerebellar form is rarely 
seen before the twentieth year. 

Pathology. — The changes found are in the posterior roots. There 
is sclerosis of the posterior columns. The spinal cord as a whole is 



536 



DISEASES OF CHILDREN. 



smaller than normal. In some cases the lateral tracts and the columns 
of Clark are atrophic, especially in the type known as the cerebellar, 
in which there is a marked diminution in the size of the cerebellum 
and degeneration of its nerve tracts. 

Symptomatology. — The gait 
is the first symptom to attract 
attention. The walk is swaying 
in character with the legs held 
apart (sailor fashion), even while 
sitting and standing the patient 
cannot control his position ac- 
curately. Athetoid movements 
or tremors are present, especially 
in the extremities. Hyperex- 
tension of the great toe may be 
an early symptom and later de- 
formities, as pes equinus, may 
develop. Romberg's symptom 
is obtained in the spinal cases, 
but is more strongly marked in 
the cerebellar type. The patellar 
reflex is variable and inconstant, 
and cannot be depended upon 
for much diagnostic aid. The 
cutaneous reflexes also remain 
quite normal. Atrophy of mus- 
cle after a time occurs and pro- 
duces such deformities as scoli- 
osis and thus destroys the normal 
spinal curves. Nystagmus is a 
quite constant symptom. The 
pupils are normal, but other 
ocular disturbances, as ptosis 
and strabismus, occur. Optic 
atrophy is not rarely found in 
the later stages. Dysarthria is 
commonly present. Sensation 
is unimpaired. The sphincters 

do not suffer. As the disease progresses signs of failing intellect are 
observed; these may be preceded by dizziness, or hysterical phenomena. 

Differential Diagnosis. — Tabes dorsalis may be differentiated by 
the absence of lightning pains and sphincteric changes, and again the 




Fig. 138.- 



-Hereditary ataxia (Friedrich'i 
disease). {Sachs.) 



DISEASES OF THE SPIXAL CORD. 537 

ataxic gait is rarely seen in infantile tabes, while the pupillary changes 
are frequent. New growths of the cerebellum might simulate a begin» 
ning ataxia, but the course is more rapid and there is headache and 
vomiting. 

Course and Prognosis. — The disease is extremely slow in its 
progress. Eyentually, after 3^earS; the patient is bed-ridden after the 
musculature is invaded. Death occurs from some intercurrent 
malady. The prognosis is invariably bad. 

Treatment. — A nutritious diet, massage, hydrotherapy, and the 
best possible hygienic surroundings are our only recourse. Medicinal 
treatment is symptomatic only. Iron is necessary for the anemia. 

Primary Myopathy. 

{Muscular Dystrophy; Idiopathic Muscular Atrophy.) 

For the purposes of clearness and to prevent the confusion which 
must arise in the mind of the reader attempting to gain information 
on this topic, we will embrace all the various described types under 
this one general title of the myopathies. 

CHnically, these types have been separated on a basis of age, as 
the juvenile (Erb type) and the infantile type; on an anatomical basis, 
for example, the facio-scapulo-humeral type (Landouzy-Dejernie); 
and still another type is based on the distal involvement, i.e., those in 
which the proximal parts of the body remain intact for many j^ears 
and only the distal parts are affected; finalh^ on an objective basis, 
in Vv'hich there is enlargement or apparent hypertrophy of portions of 
the body (pseudohypertrophic muscular paralysis of Duchenne). 

Pathological classification offers no relief at present from the ap- 
parent confusion, as the study of muscle components and muscle 
embryolog}^ has not as yet advanced sufficiently to warrant such a 
classification. 

Etiology. — Gowers suggests that the myopathies are due to an 
inherent defective vital endurance. Collins says they are an expres- 
sion of prenatal inadequate endowment. Maternal heredity seems to 
have a distinct place, while paternal heredity because of the early 
impotency of the diseased father is to be disregarded. Several 
members of one family may be attacked. The affection usually begins 
about the sixth to the eleventh years of life. Although cases have 
been reported occurring at birth, and as late as the thirties. Boys 
are more frequently seen with the disease than girls. A history of 
trauma is often given as a cause by the parents, but may be disre- 
garded in a disease of this causation. The acute exanthemata, espe- 



538 



DISEASES OF CHILDREN, 



cially scarlet fever, may so lower the resistance that the disease is 
more readily ushered in. 

Pathology. — Various anatomical changes have been found, but 
the reports are various and confusing. The nervous system does not 
seem to be involved insofar as modern technic can discover in the 
normal case. Gowers rejects the theory that the disease may be a 




Fig. 139. — Position assumed by myopathic patient climbing up stairs {Collins.) 



trophoneurosis. The cells in the dorsal ganglia have been found 
shrunken by Brooks and others. The muscles themselves show the 
true pathological changes. Atrophy and hypertrophy of muscle 
fibers may be seen in the same specimen. Fatty deposits and connec- 
tive-tissue increase are likewise found. In some cases (the pseudo- 
hypertrophic type) the adipose tissue is in excess, while in others (the 
so-called sclerotic type) the connective-tissue elements predominate. 
In the latter form the muscles become firm and thin and later simply 



DISEASES OF THE SPIXAL CORD. 539 

degenerate into fibrous bands. The lipomatous type is never hard, 
but soft and flabby. 

Symptomatology. — The first symptom noticed may be a weakness 
in walking or clumsiness in going up or down stairs; later the child 
stumbles or falls on slight provocation. These symptoms come on 
very gradually, so that they are often considered negligible in the 




Fig. 140. — Position taken by the myopathic when rising from the floor. (Collins.) 

dispensar}' patients, especially as they seem to be physically in very 
good condition. The calves may seem to the laity to be unusually 
well developed. When the disease is more advanced the gait be- 
comes waddling, the legs are not lifted much from the ground. If a 
test is now made a very characteristic attitude will be assumed, namely 
that of ''climbing up on himself;" especially if the patient attempts 
to pick an object from the floor. If placed on his back on the floor, 
the patient is obliged slowly to turn face downward, get on his knees 



540 



DISEASES OF CHILDREN. 



with the aid of his arnis, then raising his knees he forms an arch and 
now by grasping his knees he works his hands higher and higher up 
the thighs until he can assume the erect posture. In advanced cases 
even this is impossible and the child is finally bed-ridden. The 
knee and ankle reflex are diminished, and in terminal stages entirely 
absent. 



%.: 




Fig. 141 . — Myopathic boy in early stages, 
showing- winged scapulae and lordosis. 
{Collins.) 



Fig. 142. — Myopathy (hyper- 
trophic) four years duration. 
{Collins.) 



The posture is also quite characteristic. Lordosis is sometimes 
sieen quite early, and at this time it disappears if the child is asked to 
sit down. As the disease advances, the lordosis is more marked, the 
head and pelvis is held well back and no change is observed in the 
sitting position. The face loses its original expression, becoming 
dull and mask-like. When the disease is well advanced even closure 



DISEASES OF THE SPINAL CORD. 541 

of the eye-lids is accomplished with difficulty and articulation is im- 
perfect. All these changes are due to atrophy of the facial muscles 
in some degree. The lower extremities, while mainly involved, are not 
alone affected. After several years the shoulder group muscles begin 
to lose their power, the patient is unable to raise his arms and flex his el- 
bows, but they still are able to perform the finer movements of the 
hand. The supraspinatus muscle Gowers describes as being almost 
the last to become affected. The atrophic muscles allow the shoulder 
blades to recede from the thorax, forming the winged scapulae so often 
observed in the myopathies. 

Electrical Examination. — Reaction of degeneration is not ootained. 
There is, however, lessened excitability to both currents. 

Complications. — Fractures, contractures, and deformities may oc- 
cur in these cases. The fractures are due to the stumbling or awk- 
wardness of the patient. Various theories have been advanced by 
neurologists for the contractures, but suffice it to say, that they are of 
all possible varieties that are reducible and subject to relapse. 

Collins and Climenko give the following order in which the mus- 
cles are involved: 

Dense, Thickened Muscles. — calves, sartorius, glutei, triceps, del- 
toids, infraspinati. 

Atrophy. — ^Pectoralis major, trapezius, serratus magnus (anterior 
portion), latissimus dorsi, biceps, quadriceps femoris, abductors. 

Differential Diagnosis. — The characteristic features are the 
disproportionately enlarged calves, the peculiar facies, the gait, the 
lordosis and the peculiar attitude assumed when arising from the 
prone position. Atypical cases are often puzzling and must be differ- 
entiated from anterior poliomyelitis in which there is a regular corre- 
sponding distribution of the affected muscles to the portion of cord 
involved, while in dystrophy this is not so. In chronic progressive 
anterior poliomyelitis, there is, besides the regular muscle grouping, 
the reaction of degeneration and the absence of pseudohypertrophy. 
In syringomyelia the early involvement of the finger muscles serves 
as a guide, for in the dystrophies these often remain unaffected to the 
last. Progressive muscular atrophy may be confusing, but the age, 
the origin in the digital muscles and the fibrillary twitchings which 
are present will distinguish the disease. 

Treatment. — These cases, unfortunately, are not amenable to cure. 
Much can be done, however, by obtaining complete control of the pa- 
tient's daily fife. Directions should be given to supply a liberal nutri- 
tious diet. Exercises should be carefully carried out, especially 
valuable being those of the resistant form, the physician or a trained 



542 



DISEASES OF CHILDREN. 



assistant should by example teach the child the various movements. 
Electricity will assist the gymnastic movements if the faradic current 
is used. Massage will keep up to some extent the muscle nutrition, 
The orthopedist must be consulted and deformities corrected in their 
incipiency. 



CHAPTER XXXIX. 
DISEASES OF THE BRAIN. 

Meningitis. 

Pachymeningitis, an inflammation involving the dura mater, is 
rare in earl}^ life. It may occur in connection with injuries of the skull 
or ear disease, and, in acute cases, usually affects only the external 
portion of the dura. A more chronic form is seen in connection with 
hemorrhages on the vertex, when the pia as well as the internal surface 
of the dura are involved in the inflammation. Such hemorrhages are 
liable to occur in feeble infants suffering from some exhausting 
disease. This low grade of meningitis is more apt to be discovered 
at autopsy than during Hfe. 

Acute leptomeningitis, or inflammation of the pia, has already 
been described in its two most common forms — acute cerebro- 
spinal meningitis and tuberculous meningitis. There is, in addition^ 
a form that may be different in its causative factors from these two 
varieties, although there is a certain similarity in symptoms. 

Etiology. — Instead of the diplococcus intracellularis or tubercle 
bacillus acting as a cause, we may have a number of microbes, seen in 
connection with injuries of the skull, ear disease, or various infectious 
diseases, producing inflammation of the pia. In these cases it is 
more distinctly a seeondary disease. Any traumatism of the skull 
from falls or blows, suppuration after cranial operations, disease of the 
middle or internal ear or mastoids, can afford access to the various 
forms of streptococci or staphylococci that may attack the pia. It 
ma}^ also be affected by the pneumococcus, the typhoid bacillus, the 
influenza bacillus and rarely by the Klebs-Loeffler bacillus and the 
gonococcus. A meningitis may thus be seen in connection with pneu- 
monia, typhoid fever, influenza, scarlet fever, diphtheria, and as a 
terminal infection in almost any chronic infectious disease. 

Symptomatology. — The symptoms of all varieties of meningitis 
are generally alike, although differing somewhat in the course, rapidity 
and sequence of the various manifestations. As a secondary condition 
the symptoms are apt to be masked at first by the course of the original 
disease. The occurrence of projectile vomiting, convulsions, irregular 
respiration and pulse, stupor, or coma will call for a diagnosis of men- 

543 



544 



DISEASES OF CHILDREN. 



ingitis during the original infection. The symptoms will vary according 
to the part of the brain involved. Where the inflammation involves 
principally the convexity, as may be seen in pneumonia or malignant 
endocarditis, there may be no symptoms besides the stupor to dis- 
tinguish it from the original infection. Where the inflammation is at 
the base of the brain, the cranial nerves are apt to become involved and 
there will be various paralyses and some retraction of the head. Where 
the inflammation extend§ from the middle ear or mastoid, meningitis 
at the beginning will be unilateral and may continue so during the 
course of the disease, and facial paralysis may ensue on the affected side 
in addition to the other symptoms. The meninges over the first and 
second temporal convolutions are apt to be especially involved in the 
ear cases. In all varieties, when the meningitis is well under way there 
will be hyperesthesia of the skin, and there may be local or general 
convulsions, photophobia, stupor or coma, and irregularities of the 
pulse and respiration. The temperature is irregular and is influenced 
by the primary disease. The duration of secondary meningitis is 
usually short, from a few days to a week, and the prognosis is bad. 
We have, however, seen a few cases recover where the original dis- 
ease was controlled and the meningitis apparently not extensive. 

Diagnosis. — Lumbar puncture will aid in differentiating the 
various forms of meningitis by a discovery of the causative microbe 
in the fluid withdrawn. On the clinical side, the secondary nature of 
the meningitis will be shown by its onset during the course of some 
general infectious disease or when there is a recognized lesion in the 
ear that is probably being treated. Acute cerebrospinal meningitis 
is sudden in its onset, without any previous disease, and as the lesion 
is apt to involve all the surface of the brain as well as the cord, the 
symptoms are general and severe from the first. Tuberculous meningi- 
tis is very slow and irregular in its onset, sometimes taking as long as 
several weeks to attain its maximum intensity, and the brunt of the 
lesion is usually at the base of the brain. . 

Treatment. — The principal effort must be directed toward a free 
drainage of any localized suppuration in the ear or skull that may be 
causing the infection. We have seen cases of sinus thrombosis induc- 
ing meningitis, both relieved by surgical measures. The general man- 
agement is the same as in other forms of meningitis. The bowels 
must be freely opened and bromids given to relieve pain. An ice-bag 
may be intermittently applied to the head, and, if there is much evi- 
dence of intracranial pressure, lumbar puncture may be employed. 
Small doses of iodid of potash may also be tried. The nourishment 
must consist of milk, meat broths, or similar easily assimilable foods. 



DISEASES OF THE BRAIN. 545 

Acute Encephalitis. 

This is an inflammation of the brain tissue usually occurring ia 
connection with meningitis from an extension inward of the inflam- 
matory process. The symptoms are largely the same as those caused 
by inflammation of the pia. They will vary, however, as to whether 
the convexity or base of the brain is the principal seat of the disease. 
In the former case there will be convulsions, paralyses, and coma, and 
in the latter, cranial nerve paralyses will form the dominant symptoms. 
Striimpell describes a hemorrhagic encephalitis occurring in connection 
with influenza or other infectious disease. It may then be seen without 
a coexisting meningitis. There is severe pain in the head followed by 
stupor and eventually by coma. In other cases there will be great rest- 
lessness, alternating with drowsiness. There is apt to be rigidity 
of the neck; in some cases there may be loss of power in an arm or leg, 
and in others hemiplegia may ensue. Fever is present and the pulse 
and respiration are irregular. In mild cases, recovery may occur after 
one or two remissions, but, in the severer types death usually takes 
place in coma after an interval of from one to three weeks. The treat- 
ment is the same as in meningitis. On lumbar puncture the cerebro- 
spinal fluid is negative in contrast to that of meningitis. 

Abscess of the Brain. 

Cerebral abscess, single or multiple, may occur in early life. 
The white matter is more apt to undergo suppuration than the gray 
matter, and hence abscesses form more frequently within than on the 
surface of the brain. The temporosphenoidal lobes, the frontal lobes, 
and the cerebellum are most frequently attacked. 

Etiology. — Boys are more often affected than girls, and the most 
frequent cause is ear disease, especially if there is a secondary involve- 
ment of the petrous portion of the temporal bone, when the abscess 
is usually located in the temporosphenoidal lobes or occasionally in 
the cerebellum. Injuries of the skull due to trauma and sinus 
thrombosis occurring in connection with such injuries or with ear 
disease may cause abscess. Infective processes within the nose 
may spread to the brain and induce an abscess, and rarely septic em- 
boli from pus formations in distant parts of the body may be carried 
to the brain and produce a similar effect. 

Symptomatology. — As the abscesses do not commonly form in the 
motor area of the brain, the objective symptoms are often very ob- 
scure. If, however, the abscess does form or spread into a motor 
area we will have localized symptoms, the same as seen in the pressure 
effects from tumors or hemorrhage. The early symptoms are much 

35 



546 DISEASES OF CHILDREN. 

the same as those of meningitis. There is vomiting, pain in the head, 
fever, and occasionally localized or unilateral convulsions. The fever 
is irregular in type and may be accompanied by chills. If these symp- 
toms ensue in connection with acute or chronic disease of the ear, 
traumatism of the cranial bones, or more distant foci of suppuration 
that may give off septic emboli, we may suspect cerebral abscess. In 
case the abscess becomes encapsulated, there may be no symptoms at 
all, in this respect differing from the disturbing effects of solid tumors. 
Optic neuritis is occasionally present. Where the abscess is located 
at the base of the brain, the different cranial nerves may become af- 
fected. If the speech centers are involved in the abscess, aphasia may 
be noted. In some cases the pus may rupture into the ventricles, 
thereby producing serious and urgent symptoms. 

Diagnosis. — It is often impossible to differentiate abscess from 
meningitis, encephalitis, or tumors of the brain. If, in connection 
with the symptoms of brain disturbance seen in common with the 
latter conditions, there is a high, irregular fever with chills, and if 
ear disease or trauma of the skull exists, we may strongly suspect the 
formation of an abscess. A differential blood count and lumbar 
puncture may aid in establishing the diagnosis. 

Prognosis. — The prognosis is bad, but if the abscess can be located 
and treated surgically, recovery occasionally takes place. 

Treatment. — Any suppurating area involving the ear or bones of 
the skull must be carefully watched and thorough drainage maintained. 
If the symptoms point to internal abscess the surgeon must trephine 
and endeavor to open and drain the abscess. The first and second 
temporal convolutions are most often the seat of abscess following 
ear disease. The deeper-seated abscesses may be located by inserting 
a needle into the part of the brain suspected. 

Brain Tumors. 

Tuberculous tumors predominate, consisting usually of a caseous 
tumor of the cerebellum. Gliomata, sarcomata, and cysts occur usu- 
ally in the cerebellum and pons. Males are more prone than females. 
Infants under six months very rarely have brain tumors. Tubercu- 
lous and sarcomatous growths are secondary to growths elsewhere in 
the body. 

Symptomatology. — These are produced by pressure, irritation, 
exudation, or interference with the blood supply and vary also with 
the location involved. 

Headache. — This is persistent and boring in character, causing 






DISEASES OF THE BRAIN. 547 

restlessness, insomnia, rolling of the head, cephalic cry, and photopho- 
bia. Occasionally the pain is well localized at the site of the tumor. 

Nausea and Vomiting. — This is persistent and without causal re- 
lation to food. It is projectile in character. 

Vertigo or dizziness are common symptoms, elicited by change of 
position. The gait may be reeling. 

Ocidar symptoms are particularly helpful — optic neuritis in one 
or both eyes is usually present, and especially so when the cerebellum 
is affected. Optic atrophy may follow and is seen early if the chiasm 
is involved. 

Convulsions occur when the cortex and motor areas are involved. 
They are general or local in character. Tumors which have not 
as yet invaded the cortex produce paralysis and later convulsions. 

Localization. — Special symptoms will be caused by involvement 
of areas with known functions, and are not different from those mani- 
fested in adults. They will not be enumerated here. 

Diagnosis. — From abscess of the brain, tumors may sometimes 
be distinguished by the absence of local causes, lack of temperature, 
and the slower course. Septic symptoms, if present, are indicative of 
abscess, and are confirmed by blood examination. MacEwen's sign 
may be of help if other confirmatory signs are obtained. 

Tuberculous tumors occur generally in the cerebellum, and there 
may be evidences of tuberculous infection elsewhere in the body. 
Lumbar puncture should always be performed if any doubt remains. 

Treatment. — Operative procedures are carried out with great 
risk in early life even when the conditions for removal of the growth 
are favorable, but often this is the only hope for relief or cure. Medi- 
cal treatment should be directed to the relief of urgent symptoms and 
in the syphilitic cases specific medication should not be delayed. 

Infantile Cerebral Palsies. 

{Spastic Diplegia; Paraplegia or Hemiplegia.) 

There may be a paralysis of various parts of the body due to 
congenital defects, birth injuries, or hemorrhages in the brain in later 
infancy or early childhood. 

Etiology and Pathology. — We may divide the causes into those 
operating before birth, during birth, and some time after birth. During 
intrauterine life the growth of the brain may be arrested by hemorrhage, 
by lack of cortical development, or by cysts. A condition known as 
porencephaly may sometimes be present. The exact cause of these 
accidents or defects is difficult to ascertain or explain. They have 



548 



DISEASES OF CHILDREN. 



been referred to accidents during pregnancy, such as falls or blows 
on the abdomen, to uremic convulsions, to severe illness in such forms 
as pneumonia and typhoid fever, and to sudden shocks in women 
with a neurotic hereditary tendency. The causes operating during 
birth are due to prolonged pressure on the fetal head in tedious labors 
or to the unskillful use of the forceps, as already noted in the chapter 
on Birth Injuries. The hemorrhage is nearly always on the cortex, 
and may be followed by meningoencephalitis, sclerosis, the formation 
of cysts, or by atrophy of the underlying tissue. In later months or 
years, cerebral palsy may follow a severe convulsion or a prolonged 
paroxysm of whooping-cough, and occasionally certain infectious 
diseases, such as scarlet fever, small-pox, measles, and typhoid fever, 
may be responsible for the condition. Direct injury to the skull 
may also act as a cause. The rupture of cerebral vessels usually 
takes place on or near the cortex instead of in the lenticular nucleus 
as in adults. This has been explained by the delicate, fragile structure 
of the small blood-vessels on the surface of the brain. Thrombosis 
and embolism may act as a cause of cerebral palsy in children, but not 
so frequently as in later years. Rheumatism, valvular disease, or 
pneumonia favor embolism, while any exhausting condition may 
lead to thrombosis. 

Various changes occasionally take place in the brain following 
a hemorrhage. Chronic meningitis, sclerosis, softening, or atrophy, 
with various degrees of secondary degeneration and cysts, may be 
mentioned in this connection. The following tabular classification of 
infantile palsies is taken from Sachs and gives an admirable com- 
pendium of the subject: 



Groups 



1. Paralyses of intrauterine onset. 



2. Birth palsies 



3. Acute palsies (acquired) , 



Morbid Lesions. 

(Large cerebral defects (porencephaly). 
Defective development of pyramidal tracts. 
Agenesis corticalis (highest nerve ele- 
[ ments involved). 

( Meningeal hemorrhage, rarely intracerebral 
1 hemorrhage. Later conditions: Meningo- 
I encephalitis chronica, sclerosis, and cysts; 
[ partial atrophies. 

Hemorrhage (meningeal, and rarely intra- 
cerebral); thrombosis (from syphilitic 
endarteritis and in marantic conditions); 
embolism. Later conditions: Atrophy, 
cysts, and sclerosis (diffuse and lobar). 

Meningitis chronica. 

Hydrocephalus (seldom the sole cause). 

Primary encephalitis; polioencephalitis 
acute (Striimpell). 



DISEASES OF THE BRAIN. 



549 



Symptomatology. — The form and character of the paralysis 
depend on the extent and situation of the lesion. A double brain 
lesion is apt to occur early, either before or during birth. Diplegia 
or paraplegia may thus result. Hemiplegia is occasionally seen, 
although not so often, in this early paralysis, and monoplegia is rarely, 
if ever, encountered at this time. The loss of power is not apt to be 

complete, and the affected muscles 
are usually in a spastic condition. 
Very rarely the muscles may be 
flaccid. Contractures early take 
place and give rise to various de- 
formities. The groups of muscles 
most markedly affected by these 
contractures are the flexors of the 
legs and feet and the flexors and 
pronators of the arms. There is 
usually a marked exaggeration of 
the tendon reflexes. Later on there 
may be athetoid and occasionally 
choreiform movements in the palsied 
muscles. Sooner or later other evi- 
dences of cerebral defect, besides the 
paralysis, are apt to manifest them- 
selves. Epilepsy is perhaps the 
most common of these disturbances. 
Many cases of epilepsy that are seen 
in later life have had their origin in 
some hemorrhage or defect that 
originally produced a palsy in which 
recovery may have largely taken 
place. Another unfortunate sequel 
in these cases is idiocy of a mild or 
severe grade. The latter type is more apt to follow the widespread 
palsies produced by double brain lesions, and shown by diplegia or 
paraplegia. 

In cerebral palsy occurring after birth, the onset is usually sudden 
and the form hemiplegic. It is rare to have both sides of the brain 
involved, as so often occurs before or during birth. In hemorrhage 
on the cortex, there is excitation as well as loss of function, and hence 
convulsions are usually present at the beginning. In later life, when 
the hemorrhage is usually in the lenticular nucleus, there is loss of 
function, but little or no excitation. Aphasia will be noted in older 




Fig. 143. — Spastic paraplegia: 
crossed-leg progression. 



550 



DISEASES OF CHILDREN. 



children if the speech centers are involved. The paralysis is usually 
not complete and may be followed by contractures and athetoid 
movements. While there is not the marked and rapid atrophy seen 
in spinal affections^ there is usually a failure of proper development 
in the palsied muscles. There is likewise no reaction of regeneration 
as in spinal paralysis. Considerable recovery of function often takes 
place, and in some cases the prin- 
cipal disturbance will finally be 
shown by athetoid or choreic 
movements rather than by paraly- 
sis. Fortunately, mental impair- 
ment and epilepsy do not so fre- 
quently follow as in the birth 
palsies. We may say, in general, 
that these acute cerebral palsies 
occur only in early childhood, 
usually under five years. 

Diagnosis. — We may try and 
distinguish the prenatal and birth 
palsies from those occurring later 
by the history of the case and the 
extent of the paralysis, the diple- 
gias and paraplegias being nearly 
always of the early class. The 
cerebral is distinguished from 
spinal palsy by its incomplete form, 
the absence of rapid atrophy, by 
the spastic muscles, contractures 
or athetosis, exaggerated reflexes, 
and normal electrical reactions. 

Treatment. — The greatest ^^^- 144.— Hydrocephalus, with spastic 
_„ IT 1 1 paraplegia, mentality normal, 

eiiorts must be directed toward 

prevention. The expectant mother must lead a quiet, healthy fife 

during pregnancy, avoiding undue excitement and exposures that 

may lead to accident. The labor must not be unduly prolonged nor 

the fetal head allowed to undergo pressure for too great a time in the 

maternal passages. The forceps may be required to prevent this, 

but they must be applied with care, as extreme pressure from this 

source may likewise provoke a hemorrhage. After labor, if there is 

any evidence of cerebral injury, extra care must be taken to keep the 

infant very quiet. If it cannot suckle, the mother's milk may be 

carefully given by a medicine dropper. Where there are twitchings or 




DISEASES OF THE BRAIN. 551 

convulsions, small doses of bromid of sodium (2 to 3 grains) may be 
given every few hours. In the later cases of cerebral apoplexy, cold 
may be applied to the head, and a free movement of the bowels induced. 
Small doses of the bromid of sodium may likewise be given, and later 
on this may be combined with the iodid of potash. Massage and 
electricity may be used in trying to overcome contractures, but in old 
cases orthopedic appliances are usually required to overcome the 
various deformities. The services of the surgeon in cutting tendons 
and thus relieving tension and deformity are likewise often required. 

Hydrocephalus. 

Hydrocephalus is an enlargement of the skull due to fluid within 
the ventricles or in the subdural sj^aces. 

Several classifications have been made of this condition. We 
are inclined to accept the etiological as offering the greatest help to the 
student. 

1. Congenital hydrocephalus /Internal-usual, ventricular. 

^ " ^ \ External — rare, subdural. 



2. Acquired hydrocephalus 



Acute — inflammatory diseases of the men- 
inges. 

Chronic — result of inflammation of the 
external or internal coverings of 
the brain. 



Congenital External Hydrocephalus. — Very few cases of congenital 
external hydrocephalus have been reported. The condition seems to 
result from an intrauterine meningitis or from congenital maldevelop- 
ment of the brain. 

Congenital Internal Hydrocephalus. — As a result of intrauterine 
disease, there is an abnormal exudation of fluid which either, appear- 
ing early, arrests the development of the brain, or, appearing later, 
causes its atrophy. 

Etiology. — Parental alcoholism, tuberculosis, syphilis, and neurotic 
diseases have a distinct influence in its causation. 

Symptomatology. — The fluid within the cranium which ma}' be 
as much as 5,000 c.c. does not allow normal ossification to take place; 
hence the tremendous enlargement of the vault; the sutures are widely 
separated, and the enormously large fontanels may bulge. The 
bones themselves are thin plates covered with a tense skin, and the 
superficial veins are prominent. The overhanging forehead and the 
pressure within causes dislocation of the eyes, so that only small por- 
tions of the pupils are seen; the face appears abnormally small and is 



552 



DISEASES OF CHILDREN. 



usually emaciated. The expression is dull and staring, strabismus, 
nystagmus, lack of accommodation of the pupils and even atrophy of 
the optic nerve may be present. The child is pale, wasted, has a pur- 
poseless cry, and does not, as a rule, thrive even on a well-regulated diet. 
The extremities may be held in a characteristic position, that is, 
the arms are flexed and the hands clinched. The infants do not show 
any interest in their surroundings, may not recognize their parents, nor 
care for toys. Convulsions may occur from time to time. In older 
children pressure over the motor areas due to the fluid produces 




Fig. 145. — Congenital internal hydrocephalus. 



spasticity, rigidity or paralysis. Walking is delayed because of im- 
proper musculature, lack of intelligence and a tendency to the spastic 
gaitc The patellar reflexes are increased. Children who have a con- 
siderable amount of fluid are unable to support the head, on account 
of muscular weakness and the weight. A peculiar so-called hydroceph- 
alic cry is occasionally heard in these cases. In some cases the en- 
largement of the head may increase gradually or suddenly with cere- 
bral symptoms after a period of quiescence. 

Diagnosis. — In well-marked cases it is simple. The relation of 
the circumference of the head to the chest and the delayed men- 
tality should arouse suspicion. The fluid contains a trace of albumin 
and sugar. The large head in rickets is square, and other evidences of 
the disease are found in the osseous system. 



DISEASES OF THE BRAIN, 



553 



Prognosis. — This is directly dependent upon the amount and 
increase of cranial enlargement as indicated by measurements. As 
a rule, these children, especially the congenital types, succumb to inter- 
current diseases, dying soon after birth or in early childhood. Those 
cases in which the intellect is not greatly altered may be fairly bright, 
but their deformity and pecuhar gait necessitates special school 
facilities. A certain number live to be bright and useful members 
of society. 

Treatment. — Medicinal treat- 
ment is of little avail. Those with 
a syphilitic history should be given 
the benefit of the mercury and 
iodids. Surgical treatment of all 
sorts has been advised and soon 
abandoned, because of the poor 
results obtained. Pressure ban- 
dages, puncture of the ventricle, 
injections and insufflations into 
the ventricles, permanent drainage 
from the ventricles into the sub- 
dural space are among the various 
means which have been tried at 
the Post-Graduate Hospital, and 
each has been disappointing. 
Lumbar puncture, or aspiration 
of the ventricles for the relief of 
pressure symptoms, is the only 
procedure which temporarily gives 
good results. 




Fig. 146. — Acquired hydrocephalus. 



Microcephalus. 

By microcephalus we understand that condition in which there 
is arrested or defective development of the brain with a correspond- 
ingly small cranial cavit}^ 

Microcephalus probably originates during fetal life or soon after 
birth. The fontanels are closed and premature ossification of all 
the sutures takes place. The vertex is, as a rule, dome-shaped, al- 
though it may be asymmetrical with a sharply receding forehead. 
When the conditon begins later in infancy, it is considered to be the 
result of minute hemorrhages into the cortex arising from a meningeal 
disease or an eclamptic seizure. 



554 



DISEASES OF CHILDREN. 



The diagnosis of this form of idiocy is made upon the abnormality 
of the head. The measurements are taken of the head, chest, and 
length of the infant, and the relations compared to those of the normal 
infant of corresponding age (see chapter on Development). The 
symptoms do not differ from those 
of idiocy or imbecility, as described 
on page 555. The operative treat- 
ment of craniotomy which was 
formerly advanced for these cases 
we have entirely abandoned as 
giving no results. 

Idiocy, Imbecility, Feeble- 
mindedness. 

Idiocy may be divided into 
three groups: the prenatal, the 
acquired, and the myxedematous. 
In each of these the undeveloped 
intellect has been more or less 
permanently impaired. Minor 
degrees of idiocy are designated 
as imbecility or feeble-minded- 
ness. The mental impairm^ent 
being dependent upon the extent 
of the cerebral lesion. 

Etiology. — The children of in- 
sane parents or of those who have 

been the victims of alcoholism, epilepsy, hysteria, chorea, or syphilis 
may be born idiotic. Consanguineous marriages, especially among 
those who have suffered from some neurotic disease, may produce 
idiotic children. The acquired types are generally the result of 
injuries received at the time of birth and from convulsions, both of 
which result in the rupture of delicate blood-vessels, with later sclerotic 
changes. This latter change may also take place after attacks of 
inflammation of the brain or its meninges. The relation of idiocy to 
hydrocephalus and epilepsy has been considered elsewhere. 

Symptomatology, — From the physical standpoint an idiot may 
resemble a normal child. He radically differs, however, in his powers 
of cerebration. He is unable to acquire any conceptions and he has 
no sense of fear. As a rule, the diagnosis can be made by observation 
alone. The expression is vacant and the eyes are continually roving 




Fig. 147. — Microcephalus, with double 
hare-lip. 



DISEASES OF THE BRAIX, 



ooo 



from place to place. In younger children saliva dribbles over the 
chin. The teeth may be irregularly erupted and usually are sharp 
and carious. Other stigmata of degeneration may be seen. The 
child cannot distinguish its parents, it has no acquired speech, but 
makes unintelligible animal sounds, it becomes irritated or laughs 
without provocation, and when aAvake keeps in constant motion. 





Fig. 148. — Imbecile with marked 
strabismus. 



Fig. 149. — Idiocy, with blindness. 



There are no habits of cleanliness. Food is eaten ravenously and 
not selected with any relation to taste or desire. Imbeciles and 
feeble-minded children differ from idiots in that they may be able to 
recognize their parents and appreciate some simple objects, as toys. 
A few Avords may be learned and habits of personal cleanHness may 
after a time be acquired. 

Prognosis. — The prognosis for the idiotic child is invariably bad. 



556 



DISEASES OF CHILDREN. 



The feeble-minded are capable of some degree of development when 
placed under special tuition. 

Treatment.— The parents of idiots should be advised that an 
institution is the proper place for their afflicted child, especially if 
there are other children in the family. Here he will be unmolested and 
allowed more freedom than is possible when in his home. 




Fig. 150 .—Idiocy. 

Feeble-minded children, if the circumstances permit, may be 
placed in institutions arranged for the care and training of mental 
defectives, where under almost private tutelage they may be trained 
along the lines in which they show any aptitude. In some of our 
States such institutions have been provided for these unfortunates, 
so that even the children of the poor may receive this beneficial training. 



Mongolian Idiocy. 

This form of idiocy because of several simulating features is 
often mistaken for cretinism. The resemblance to cretinism is seen 



DISEASES OF THE BRAIX. 



557 



in their stunted development, in the large and often protruded tongue, 
the thickened lips, and open mouth. A MongoKan idiot, however, 
may, even in infancy be distinguished by the pecuhar expression of 
the face, which when analyzed is seen to result from slanting eyehds 
like those seen in the MongoHan race. Although the eyes converge, 
they are relatively further apart than in the normal, the nose is small 
and flat and the contour of the head is distinctly rounded. The skin 
in the early months is not harsh and dry, it may be soft and velvety. 
A rather characteristic feature is seen in the flabby muscles and 





f 


■^ i: 








^ 


J 


r- 


|:j 


i 


. 


'■'- ^*'"" € 



Fig. 151. — Mongolian idiocy. 



mobility of the joints, which allow the thighs, for example, to be 
flexed with extraordinary ease upon the body. The head is not held 
erect until the age is well advanced, the fontanels remain open late 
and the nutrition is impoverished in spite of good feeding. The bones 
of the hands and wrists show deviations from the normal which are 
best seen in a radiograph, although the incurvation of the little finger 
and the short second phalanx is often easily discernible. 

The mongoloid idiots further differ from the cretins in that they 
are not influenced by thyroid therapy, and if they pass through the 
period of infancy they may show some degree of intelligence. 



558 



DISEASES OF CHILDREN. 



Amaurotic Family Idiocy. 

This is a disease occurring in Hebrew families and dependent upon 
arrested cerebral development and characterized by blindness and 
changes in the region of the macula lutea. 

Tay, an oculist, first described the ocular symptoms, while 
Sachs, in this country, further elaborated the cHnical and pathological 
picture. 

Etiology. — The causes of this disease are still undetermined. 
More than one case may occur in the same family, and all the cases 
thus far observed have been among Hebrews. 




Fig. 152. — Amaurotic family idiocy. {Sheffield.) 



Symptomatology. — The first symptoms appear about the sixth 
month. Up to this time the child may have been considered healthy 
and robust. The first symptoms noted are that the child makes no 
effort to hold up its head, moves its limbs only slightly, and takes no 
interest in those about him. If some degree of nystagmus is present 
the fact that the child is blind escapes the attention of the parents or 
even of the physician. If seated the head falls back and the lower 
extremities give evidences of complete paralysis. Later in the 
disease spasticity occurs in these extremities with increase of the 
reflexes. As the disease advances the weakness becomes intensified, 
and usually after the first year there is total blindness and evidences 



DISEASES OF THE BRAIN. 559 

appear of mental deficiency. Strabismus is occasionally observed 
and is usually associated with the nystagmus. Convulsions are rare. 
The hearing may be abnormally acute, the infant being startled from 
its apathy, for example, by clapping the hands. Ophthalmoscopic 
examination fixes the diagnosis when Tay-Kingdon's cherry-red spots 
on a white background is found in the region of the macula lutea. 
Subsequently, optic nerve atroph}^ results. Before the fatal ending 
emaciation and other subjective and objective symptoms of marasmus 
appear. The prognosis is invariably bad, the children rarely living 
beyond the second year. 

Treatment. — Beyond giving the prognosis as to the duration of 
life we are powerless to give aid in this disease. 



SECTION XIV. 

CONGENITAL MALFORMATIONS AND 
DEFORMITIES. 



CHAPTER XL. 

CONGENITAL MALFORMATIONS AND DEFORMITIES. 

A careful examination should always be made of the newly-born 
child. Any deviation from the normal condition may be due to pre- 
natal malformations, as well as to injuries received during the process 
of birth. 

Tongue-Tie. 

A short frenum causes this deformity. The tip of the tongue 
is depressed and fixed in the floor of the mouth so that often it cannot 
be protruded. Sucking and articulation are difficult, and when 
allowed to persist there is often a lisp in the speech. 

The treatment is surgical, and consists in dividing the frenum 
with blunt scissors and stripping back the divided tissue with the 
finger-nail. Parents often attribute backwardness in talking to a 
possible tongue-tie. Mental defects or deafness may instead be found 
as the real cause if the child is much beyond the age when it should 
be talking. 

Harelip. 

When the central process fails to fuse with the lateral processes 
which go to make up the upper half of the face in fetal life, a condition 
known as harelip results. This may be unilateral or bilateral, the 
fissure varying in extent from a shght cleft to a fissure extending 
through the entire length of the lip into the nasal fossa. 

The treatment is surgical, and should be undertaken as soon as 
possible after the child is well started in its feeding— three months of 
age being the time selected by the majority of surgeons. Nursing 
is sometimes impossible, but the maternal milk should be pumped out 
and fed by the dropper or the Breck feeder (see Fig. 3). A nipple 
shield can sometimes be used to advantage, or the milk can be fed 

560 



COXGEXITAL MALFORMATIONS AXD DEFORMITIES. 561 

from a nursing bottle when the babe cannot suckle the mother's 
breast. Nursing should not be discontinued except for exceptionally 
good reasons. 

Cleft Palate. 

In this condition a fissure is seen in the roof of the mouth, in- 
volving the soft palate, the 'hard palate, or both. 

It occurs when the palatal arches in fetal life fail to fuse. Cleft 
palate often occurs with harelip, particularly when the latter con- 
dition is double. 

Owing to the gap in the mouth the infant usually cannot nurse 
nor feed from a bottle, and it is often necessary to resort to feeding 
with a dropper or by gavage. Xipples with a flexible wing have been 
devised to accommodate these cases for bottle feeding, the flap being 
so arranged that it fits snugly to the upper lip and covering the cleft. 

Such deformities as cleft palate and harelip make feeding very 
difficult, and these cases frequently die of inanition. 

The treatment is surgical; the operation should be performed 
as early as possible. The surgeon who is to operate must decide upon 
the preferred age, which depends upon the character of the operation 
and the nutrition of the child. Some surgeons operate at the end of 
the second year, while others prefer to wait until the arches are well 
developed. 

Congenital Branchial Cysts. 

Certain tumors of the neck in infants and young children have 
their origin in an incomplete closure of one of the branchial clefts. 
Early in the fetal life of the vertebrata there appears under the pro- 
jecting frontal process a series of four plates, bounding the cavity of 
the pharynx on the side. These plates unite to form four parallel 
arches separated by transverse clefts. The branchial clefts unite, and 
by a process of morphological change form various structures of the 
neck. If this regular process of development is interfered with 
from any cause, various abnormalities may result, as a condition 
intended to be merely temporary remains more or less, permanent. 
Hence, according to the various grades of arrested development, we 
may have marked deformities, branchial cysts, or the remains of fetal 
epithelial tissue destined to proliferate at a later day and form a cyst. 
There likewise may result fistulous tracts from non-union of the 
branchial clefts, particularly from the lowest one. These have been 
divided into: (a) complete branchial fistulse, open the whole length of 
36 






562 



DISEASES OF CHILDREN. 



the tract; (b) fistulse having only an external orifice and ending in a 
cul-de-sac, which is the commonest form; (c) fistulse with only an inter- 
nal orifice. More frequently the branchial tract is closed at both the 
pharyngeal and cutaneous ends, and a cyst is formed between. 

Senn has made the following classification according to the cystic 
contents: 1. Mucous branchial cysts, due to imperfect closure of the 
upper portion of the branchial tract with retention of its physiological 
secretion. 2. Atheromatous branchial cysts, usually located in the 
second and third branchial tracts in the region of the hyoid bone. 3. 





Fig. 153.— Branchial cyst in an infant. Fig. 154.— Branchial cyst in a boy 

8 years old. 



Serous branchial cysts, having a thin-walled capsule lined with pave- 
ment epithelium, and following the defective obliteration of any of 
the branchial clefts. 4. Hemato-cysts of branchial clefts, in which 
the serous fluid of the cyst has been discolored by hemorrhages into 
the sac. 

The contents of these cysts are always such as may be produced 
by some kind of epithelium, and in this they differ from true dermoid 
cysts that may contain the secretion of the various glands and append- 
ages of the skin. 

The two illustrations show branchial cysts in an infant five days 
old and in a boy of eight years (Figs. 153 and 154). 

Treatment. — The object of treatment in these cases is, of course, 



COXGEXITAL MALFORMATIOXS AXD DEFORMITIES. 563 

to radically destroy the membrane that secretes the serous contents 
of the tumor. In structure, the cyst consists of a thin capsule of 
connective tissue, lined on its inner surface by a matrix of epithelial 
cells, which must be destroyed b}' an inflammation set up in the sac 
or removed by the knife, before recovery can take place. As these 
cysts may be connected with the sheath of the deep cervical vessels, 
complete removal by operation may be attended by severe hemorrhage 
unless very great care is exercised. When fistulse exist, they may be 
destroyed by passing in a probe which has been dipped in a 10 per 
cent, nitrate of silver solution. If excision of the cyst is not feasible 
it may be opened and packed with gauze. 

Malformations of the Esophagus. 

This malformation is quite rare. The diagnosis is generally 
made probable by the inability of the infant to take or retain any 
feedings, or the return of such feedings through fistulous tracts. 
The stomach-tube cannot be passed at all or meets an obstruction or 
stricture. 

Various degrees of malformation occur, such as narrowing in its 
entire length, leaving only a band-like process, openings into the 
trachea or externally into the neck. Blind pouches also have been 
found. 

Treatment. — Skilled surgical treatment may avail in the minor 
degrees of malformation, but the early age and severity of the operative 
work mitigate against success where prolonged procedures are 
necessary. 

Malformations of the Rectum and Anus. 

A stenosis of the anus may be present, due to abnormal encroach- 
ment of the skin upon the anal mucocutaneous tissue. The rectum 
itself may be congenitally too narrow. 

The treatment of both these conditions is mechanical dilatation 
with the fingers or a bougie. 

The anus may be imperforate due to non-absorption of the cuta- 
neous envelope, the integrity of the rectum being normal. Treat- 
ment of the abnormality is by incision and removal of the obstructing 
tissue. 

There may be an obstruction in the rectum, the anal structure 
being normal; that is, the large intestine may terminate in a blind 
sac having no communication with the anus, or it may have a small 
fistulous connection. Occasional!}^ there is a membranous velum 



564 



DISEASES OF CHILDREN, 



with a very small aperture across the rectum. The treatment is 
surgical. Careful inspection and examination of the newly-born 
by the attendant will reveal the deformity, and immediate steps should 
be taken to obtain surgical correction. 

The time of the passage of the first stool and its size and character 
should always be investigated by the attending physician. Minor 
degrees of stenosis of the rectum or anus are not infrequent in the newly 
born. Although the thin feces of infancy may escape without diffi- 
culty, when the child grows older and the excreta become more solid 
stenosis may occasion much inconvenience. 




Fig. 155. — Hypospadias. 



Hypospadias. 

The anomaly in male genital organs in which the urethra opens on 
the under surface of the penis instead of at the point of the glans, is 
known as hypospadias. This exit may be located at any point on the 
penis from tip to base, and is designated according to location, as 
glandular, penile, peniscrotal, or perineal. In the perineal type, 
hermaphrodism may be suspected, as the testicles are often unde- 
scended, the penis rudimentary, and the scrotum divided by a deep 
fissure. 

The passage of urine is usually difficult. Dripping of urine from 
an overdistended bladder is the cause of incontinence in these cases. 



CONGENITAL MALFORMATIONS AND DEFORMITIES. 565 

The treatment of hypospadias is surgical and often is tedious, but ex- 
perienced operators now obtain very satisfactory results with flap- 
method operations. 

Extrophy (Ectopia) of the Bladder. 

This deformity is characterized by Ahlfeld as ''a fissure in the 
abdomen of an otherwise well-formed fetus, which is lined with a bright 
red, velvet-Hke skin (the bladder membrane), and which is constantly 




Fig. 156.— Extrophy of the bladder. 

kept moist by the urine which trickles upon it. Below the fissure, 
in the abdomen and bladder, are to be seen incompletely developed 
external genitals.'^ 

The only treatment is plastic surgery, and the results are often 
quite brilliant, although several operations are usually necessary 
before a satisfactory repair is made. 

Congenital Dislocation of the Hip. 

The cause of this deformity is not known, but some cases are 
doubtless due to fibroid tumors in the uterine wall producing a mal- 
position in uiero. Lange distinguishes three forms: the supracoty- 
loid, the supracotyloid and iliac, and the iliac. 

The condition is rarely noted in early infancy, as the symptoms arq 



566 



DISEASES OF CHILDREN. 



not in evidence until the patient begins to walk. The leg is short- 
ened and flexed on the pelvis, and when the dislocation is bilateral 
there is a considerable lordosis present when the patient stands erect. 
If the dislocation be unilateral a scoHosis results. A pecuHar waddling 
gait is quite characteristic of these cases. When there is much con- 
traction of the adductors the lower ends of the femurs cross each 
other, forming the scissor-leg deform- 
ity. This, however, is rare. A Roent- 
gen photograph will clear up any 
question as to the diagnosis. A re- 
duction of the dislocation is more 
readily made when the patients have 
not done much walking, as owing to 
the shallow acetabulum it is impossi- 
ble to keep the femoral head in place 
unless the patient remains in bed. 

Treatment. — The bloodless re- 
duction method advocated by Lorenz 
is usually selected by the surgeon as 
offering the best results. A plaster 
dressing is applied which must be 
worn for months, and later massage 
and exercises are ordered. This 
operation should not be delayed too 
long, as in older children good results 
are rarely secured. 




Fig. 157. — Congenital deformity 
of the hand. 



Congenital Absence of the Bones. 

Among the rarer bony deformities there is occasionally seen an ab- 
sence of the radius. This is a bilateral defect, and produces a serious 
incapacity in the physical strength and ability of the extremity af- 
fected. An incurvation due to abnormal muscular attachments 
results, as illustrated in the radiograph (Fig. 160). 

Fig. 157 is a radiograph showing absence of the greater portion 
of the phalanges. 

Fig. 159 shows an absence of the hands beyond the carpals as a 
result of intrauterine amputation. 

Talipes. 

(Club-foot.) 
Congenital talipes results from malformation or lack of develop- 
ment of the bones about the ankle. A small uterus with deficient 



CONGENITAL MALFORMATIONS AND DEFORMITIES. 



567 



liquor amnii may produce a talipes by abnormally compressing the 
parts, the normal position of the feet in utero being a talipes varus. 

All acquired talipes are due to pathological conditions; for example, 
following anterior poliomyelitis or contractions of tissues after exten- 
sive burns or diffuse suppurations, and as the result of the overaction 
of certain muscle groups when the nerve trunk supplying their equilib- 
rants is affected. 




Fig. 158. — Double congenital dis- 
location of the hip. 



Fig. 159.- 



-Intra-uterine amputation 
of the hands. 



In fact, any process which will change the normal equilibrium of 
muscle groups about the ankle will produce a talipes. The cause 
may be found in the bony or ligamentous structures or in the muscles. 

Talipes varus is the most frequent variety seen in congenital cases. 
In this form the patient walks on the outer surface of the ankle, the 
inner surface of the foot being raised. 

Talipes equinus results when the heel is elevated and the patient 
walks on his toes. This form results from paralysis of the extensor 
muscles of the leg with secondary contractions of the muscles of the 



568 



DISEASES OF CHILDREN. 



calf, and occurs following anterior poliomyelitis or injuries to the 
anterior tibial nerve. 

In talipes valgus the patient walks on the inner surface of the 
ankle, the outer border of the foot being raised and everted. A 
paralysis of the tibial muscles produces this deformity. 

Tahpes calcaneous is rare; the patient walks on his heel with the 
toes elevated. This deformity arises when the calf muscles are 
paralyzed. 





Fig. 160 . — Congenital absence of the radius. 



Treatment. — In congenital cases daily manipulation of the foot 
and ankle should be instituted at once until the deformity is 
overcorrected, the foot being retained in good position by mechanical 
means such as a cast or apparatus. 

In paralytic cases manipulation and massage is indicated, special 
attention being given to the weakened muscle groups, toning them up 
by the use of f aradism and friction. A proper splint should be applied 
to retain the foot and ankle in the correct position. Tenotomy and 
other operative measures may be necessary in neglected cases. 



CONGENITAL MALFORMATIONS AND DEFORMITIES. 



569 



Webbed Fingers and Toes. 

{Syndactylism.) 
In this condition two or more fingers or toes are joined laterally 
by a web which, if thin, consists mainly of skin, but if thick more or 
less flesh3^ tissue is present. If the fingers be affected, the web must 
be divided, care being taken to insure full separation to the base of the 
fingers and the separation maintained. If the web be thin the oper- 
ation consists in incision only; but if the web be fleshy, skin flaps 
must be made and the denuded surfaces covered. Webbed toes 
need not to be treated unless for the cosmetic effect. 




Fig. 161. — Congenital club feet in an infant with a spina bifida. 



Meningocele and Encephalocele. 

Owing to a congenital opening at some part of the skull, a portion 
of the cranial contents may protrude. The defect is most common in 
the occipital bone, in any portion of Avhich the defect may be present, 
from the peripheral part to the center. If it exists in the anterior 



570 



DISEASES OF CHILDREN. 



portion of the bone, it may extend to the posterior fontanel; if in 
the back part, it may connect with the foramen magnum. The size 
of the tumor depends, of course, upon the extent of the opening in 




Fig. 162.— Webbed fingers. 

the bone. Similar defects may also be present in the nasofrontal 
region, and less frequently in the basilar, temporal, and parietal seg- 
ments of the skull. The openings may contain meninges alone, men- 




FiQ. 163. — Supernumerary thumb. 

inges with brain matter, or the latter with fluid in the interior; in 
the latter event the anomaly is termed hydrencephalocele. The 
tumors appear at or soon after birth. 



CONGENITAL MALFORMATIONS AND DEFORMITIES, 



571 



A meningocele is usually small, with little tendency to increase in 
size. It may be more or less pedunculated; it presents fluctuation, 
but no pulsation, and is usually reducible. 

In encephalocele there is distinct pulsation, and efforts at com- 
pression will be accompanied with evidences of marked cerebral 
irritation. The tumor, though not large, has a wide base, and is 
partly reducible. 

A hydrencephalocele is apt to be large, lobulated, with sometimes 
a distinct peduncle. Pulsation is usually absent in the tumor, which, 



■^.^ 




Fig. 164. — Meningocele. 

however, is fluctuating and mostly translucent. Compression is not 
apt to be successful in reducing the tumor. Sometimes there is more 
brain substance in the tumor than in the cranial cavity, and the infant 
is then microcephalic. 

Prognosis. — The prognosis in hydrencephalocele is bad, as the 
tumor usually grows rapidly, and there may be rupture, with im- 
mediate death. In meningocele and en'cephalocele the prognosis is 
better, especially if the tumor be small. 

Treatment. — Treatment in these cases is of little avail, although, 
the withdrawal of fluid and even stimulating injections have been tried. 



572 



DISEASES OF CHILDREN. 



Spina Bifida. 

Owing to congenital failure in the development of the vertebral 
arch, one or more of the laminae may be absent, with resulting pro- 
trusion of the spinal meninges. The lumbar region of the spinal 
column is the part usually affected. Occasionally, however, we have 
meningocele or encephalocele. The tumor is round, fluctuating, and 
by compression the cerebrospinal fluid can be forced back into the 
spinal canal. Too severe pressure, however, may produce eclampsia 

or other grave cerebral symptoms. 

The base of the tumor depends upon 
the size of the opening, being pedun- 
culated if it is small, but more sessile 
if large. The tumor is usually covered 
with skin, which, however, may be 
absent, exposing the dura mater. If 
there is not much tissue covering 
the tumor, transudation may occur 
through the walls or rupture of the 
sac may take place if growth is rapid. 
Some portion of the lower segment of 
the cord or the cauda equina is apt to 
be imprisoned in the sac. The extent 
of the involvement of nerve-tissue can 
be measured by the paraplegia or 
other evidences of lesion in the spinal 
cord and nerves. 

Gradual absorption of the fluid 
may occur, and the child may grow 
up with little inconvenience from, the 
shrivelled tumor. This, of course, 
takes place only when the nerves are 
not involved. In most cases there is 
a gradual increase in the size of the tumor, with final ulceration or 
rupture, followed by convulsions or coma and death. The fatal ending 
may also come with a gradual emaciation accompanying paraplegia. 

Treatment. — The treatment of small tumors consists in the 
application of a soft compress to avoid friction and to support the 
parts. When the tumor is growing, however, more energetic measures 
may be tried. The simplest procedure is to withdraw the fluid by 
aspiration, and follow this with gentle but constant pressure. The 
fluid must be slowly and cautiously removed, for fear of active nervous 




Fig. 165,— Spina bifida. 



CONGENITAL MALFORMATIONS AND DEFORMITIES. 573 

disturbance and even eclampsia. Injections with iodin of various 
strengths have been tried, but without much success. In some cases 
the tumor can be surgically removed by completely excising the sac. 
This may be successfully accomplished in the pedunculated variety 
where the opening in the lamina is small. It should never be attemped 
if there is evidence that the cord or cauda equina may be involved in 
the tumor. 



SECTION XV. 
THE COMMONER SURGICAL DISEASES. 



CHAPTER XLI. 

THE COMMONER SURGICAL DISEASES. 

Anesthesia. 

The administration of an anesthetic to a child is often rightly 
viewed with apprehension by the practitioner, and questions arise 
as to the best method and safest anesthetic to employ. 

The same phenomena are observed in early life as in adults, but 
the margin of safety is less, and thus the use of any anesthetic should 
be regarded as a factor by itself and given the consideration it de- 
serves in relation to the age, the physical condition of the patient, 
and the character of the operation he is to undergo. It should be 
recollected that any anesthetic given beyond its proper limits is a 
cardiac depressant. 

Choice of Anesthetic. — Ether is preferable if the anesthetist is not 
thoroughly experienced; if the period of insensibihty is to be a long 
one; in cardiac diseases and in operations for the relief of obstructed 
respiration, as Ludwig's angina, papillomata of the larynx or deep 
cervical adenitis. It is also to be preferred if the patient must be kept 
in an erect or semi-erect posture. 

Chloroform in the hands of an expert in anesthesia is preferable 
to ether. Children are rapidly brought under its influence as they 
usually cry and thus inspire rapidly. Plenty of air, constant vigilance, 
and the utilization of the drop-by-drop method, depending on each 
minim administered to add to the effect, is the proper procedure. 

In minor surgical affections in which only a primary anesthesia 
is required, chloroform is of advantage, as the patient rapidly comes 
out of its influence without the nausea and vomiting which are so 
often seen with ether. Chloroform is preferable if nephritic condi- 
tions are present, or a possibility, as in suppurative adenitis following 
scarlatina. Lividity of the lips, with an ashen-pale face and weak 
slow pulse are indications that should be met by immediately stop- 
ping the anesthetic, inducing free respirations and by hypodermatic 
stimulation. 

574 



THE COMMONER SURGICAL DISEASES. 575 

Gas -ether anesthesia, in the hands of professional anesthetists, 
is the method to be selected for older children, but in infancy and 
the first years of life the nitrous oxid gas is poorly borne and liable to 
cause suffocative cyanosis. 

Anesthesia, according to the method of Schleich, or the spray 
method with ethyl chlorid is satisfactory in the hands of those accus- 
tomed to them, but cannot be commended for general use. 

Preparation for Anesthesia. — Feeble children should not be denied 
food for a longer period than three or four hours before administering 
the anesthetic. Often a small amount of a hot Hquid, such as thin 
gruel, will be effective in preventing collapse of the infant. The bowels 
should be moved by a soap-suds enema, and in older children a dram 
or two of licorice powder should be given the night before. As the 
bodily heat is easily dissipated, especially in infants, they should not 
be unduly uncovered, and artificial heat may be applied during the 
operation with favorable effect. A preliminary stomach washing in 
cases of intestinal obstruction with incessant vomiting should precede 
the operation. Hypodermocylsis and a nutrient enema may also be 
indicated in certain feeble or anemic infants in whom collapse is feared. 

Hernia in Early Life. 

Hernia occurs in young children as a result of arrest or defective 
development of the fetus, which allows the protrusion of some of 
the abdominal contents through a natural opening. 

Etiology. — Hernia in early life may be in the order of their fre- 
quency, inguinal, umbiUcal, ventral, and femoral. 

Inguinal hernia occurs more commonly in boys than in girls, and 
we are inclined to agree with Russell that this form is essentially due 
to a preformed sac or an obliterated portion of the vaginal process. 
Such a sac results when a part of the peritoneum coming down in 
front of the testicle as it passes into the scrotum in fetal life fails to be 
obliterated and separated from the remainder of the peritoneal cavity. 
Thus oblique or indirect hernia is congenitally formed. Coley sug- 
gests that the terms '^congenital" and "acquired" be abandoned 
and that we adopt instead the classification of total or partial funicular 
sacs. Direct and femoral hernias are in the majority of cases acquired., 
as they rarely result from congenital sacs. 

The most common predisposing causes other than the anatomic are 
constipation, pertussis, tympanites, crying, straining, and coughing. 

Symptomatology. — The signs do not differ very materially from 
those found in the adult. A tumor may appear and reappear several 



576 DISEASES OF CHILDREN. 

times before attention is directed to it. The tumor gives an impulse 
to the finger on crying or laughing; it may disappear spontaneously 
on lying down, it may cause discomfort or even pain at this time of life, 
and if the intestine has protruded a sensation of gurgling is felt when 
the tumor contents slip into the abdominal cavity. Strangulation is 
not common, and when it occurs results from constriction at the exter- 
nal abdominal ring, from tough and inelastic fibrous bands or rings 
which may be found within the sac (De Garmo) or from fecal impac- 
tion. The symptoms of this complication are, besides the tumor itself, 
nausea and vomiting, constipation with abdominal distention, pains 
of a colicky character which are increased on urination, increased pulse 
rate, a variable amount of temperature, restlessness, and if relief is 
not obtained at this point vomiting becomes stercoraceous with sub- 
normal temperature, and a fatal issue will result. 

Diagnosis. — The differential diagnosis is given on page 503. 

Treatment. — The great majority of children under three years of 
age can be cured by mechanical means. This implies the proper ap- 
plication of a suitable truss. This should be made of hard rubber with 
a slightly convex pad of the same material, or consist of a water pad 
covered with impervious, water-proof material. These are recom- 
mended because they can be readily adjusted and kept clean. Leather 
trusses soon become soiled or soaked with urine and produce excoria- 
tion. The physician himself should select and fit the truss, the spring 
should be just strong enough to properly retain the hernia even when 
the child cries or strains. It should be applied only in the prone posi- 
tion and worn continually day and night. Parents should be warned 
not to unnecessarily remove it unless the child is lying down and the 
hernia meanwhile digitally retained. A cure is generally affected 
within a year, although it is advisable to retain the support for a year 
and a half. If after this time the tumor still protrudes on exertion, 
recourse must be had to operation. 

Children over six years of age are rarely, if ever, cured by the 
application of a truss. 

The treatment of umbilical hernia has been discussed and illus- 
trated on page 16. Operation is indicated immediately in all cases 
of strangulated hernia. It is necessary in hernia complicated with 
irreducible hydrocele, in femoral hernias, and in children over four 
years of age who have not been cured by the application of a properly 
fitted truss worn over the prescribed period. 

The Bassini operation, which is founded upon the etiological factors 
involved in the production of hernia, almost invariably gives most 
satisfactory results in competent hands. 



THE COMMONER SURGICAL DISEASES. 577 

Circumcision. 

Many male infants need circumcision. The operation promotes 
fleanliness and inhibits the formation of the habit of masturbation. 

In cases in which the adhesions about the glans penis have been 
separated and the prepuce still does not sufficiently retract, circum- 
cision is indicated. It is certainly necessary in all cases in which the 
prepuce is tight enough to hold drops of urine or when it balloons 
out on urination. The prepuce should be so trimmed that the corona 
is covered and only enough should be cut away so that the prepuce 
can move freely over the glans. In this way its physiological purpose 
will be preserved. 

This operation should be performed in the early months of life. 
It should be unnecessary to say that surgical cleanliness is to be ob- 
served. With a pair of hemostatic forceps stretch the prepuce, and 
insert a director between it and the glans. Then incise along the dor- 
sum in the middle line to a point just proximal to the corona. Sepa- 
rate all adhesions until the coronal sulcus is defined and remove all 
smegma. Cut away the redundant tissue, including both sldn and 
mucous membrane from both sides down the frenum. After all the 
edges have been carefully trimmed put in three or four fine plain cat- 
gut sutures to prevent any exposure of raw surface. Bleeding is 
slight and probably no ligatures will be required. Use plain gauze 
strips covered with sterile vaselin for a dressing. If the suture mate- 
rial used is non-absorbable, remove the sutures on the fifth day and 
powder the wound with aristol. 

Appendicitis. 

Etiology. — Appendicitis is comparatively rare in early life. In 
infancy it is extremely uncommon. Invasion of the lymphoid struc- 
ture of the appendix by bacteria is made possible by traumatism from 
within or without, by intestinal parasites, mucous inclusion, or con- 
strictions harboring fecal masses. 

From a pathological standpoint the disease in children does not 
materially differ from that found in the adult. It should be recol- 
lected, however, that the appendix in children is normally not larger 
in diameter than a goose-quill; that it is more apt to be found in 
diverse situations and that it normally lies higher in the abdomen. 
Suppuration takes place more readily and localized abscess forma- 
tions are not unusual. In quite a number of our cases, children with 
37 



578 DISEASES OF CHILDREN. 

appendicitis were willing to walk about or sit up even when ulcerative 
conditions were subsequently found at laparotomy. 

Symptomatology. — In the acute inflammatory form the child may 
complain of indefinite colicky pains which are often attributed by the 
parents to some indiscretion in diet, especially when vomiting occurs 
early. The fever is not high, rarely rising above 102° F. If the patient 
is walking about, he usually stoops and his movements are made 
cautiously. After being placed in bed he may prefer to lie on his back, 
drawing up the knees to relax the abdomen. Although if asked to do 
so he may not hesitate to turn to either side or extend the thighs. 
The area of pain may not be definitely located by the patient in the 
right iliac fossa; in fact, he very often refers it to the umbilical 
region. 

Examination. — On inspection the contour of the abdomen is 
usually found to be normal; there may be sHght distention observable. 
Palpation, carefully performed, so as not to excite undue muscular 
effort may elicit some resistance and tenderness in the right iliac fossa. 
In children it is seldom that a definitely localized spot of tenderness 
is found over McBurney's point. In thin subjects, however, it may 
be possible to definitely locate the inflamed appendix. If the diag- 
nosis is still in doubt, bi-manual rectal examination should be made 
according to the method described on page 48. A low grade of leu- 
kocytosis is usually found in this type. 

Such a case of appendicitis may subside under medical treat- 
ment, but recurrences are almost sure to follow at some future time 
making the prognosis graver than if operation is performed at once or 
in the interval. 

The suppurative form with a tendency to perforation at or near 
the tip occurs more commonly and the symptoms are more severe. 
The pain may come on suddenly with fever, nausea, and vomiting, 
constipation and tympanites occur, the patient generally seeks his bed 
and is satisfied to lie quietly in the recumbent posture. The legs 
are drawn up and the patient localizes the pain more definitely to the 
right iliac fossa. The temperature varies between 101° and 103° F. 
and rarely rises above this point; the fever may not reach higher than 
101° F. The pulse rate is increased, especially so if perforation takes 
place. Gangrenous changes may occur and may be suspected if 
the subjective or constitutional signs are more marked. 

Examination. — On inspection, the attitude of the patient with 
the knees drawn up, the facies showing distress, the coated tongue and 
the distended abdomen with suppressed abdominal respiration should 
be suggestive. On palpation of the right side the muscular rigidity 



THE COMMONER SURGICAL DISEASES. 579 

is marked and a distinctly painful area of tenderness may be mapped 
out. In some cases the tumefaction or mass can be quite easily felt. 
Rectal examination should confirm these findings. Repeated blood 
examinations will show varying percentages of polynuclear elements 
ranging from 85 to 95 per cent. If peritonitis has resulted, the ab- 
dominal rigidity is increased and vomiting again occurs, the abdomen 
is distended with gas, obscuring the liver dullness. When the peri- 
tonitis is localized about the caput coli the inflamed appendix may be 
walled off from the general cavity. This is indicated by a diminution 
of the general symptoms. 

An abscess may form within this area from perforation, gangrene 
or rupture of the appendix. Fluctuation may be obtained, but even 
before this a sudden drop in the temperature curve points to a focus of 
pus. A differential leukocyte count will also act as corroborative evi- 
dence when the percentage of polymorphonuclear leukocytes is greater 
than eighty. • 

Diagnosis. — Cases presenting the classical symptoms of pain in 
the right iliac fossa with rigidity of the right rectus muscle, tumefac- 
tion, fever, and vomiting should occasion little or no difficulty in diag- 
nosis. Examination under a general anesthetic may sometimes be 
necessary in doubtful cases, especially if a skilled surgeon is not at hand. 
Intestinal obstruction is to be differentiated by the absence of initial 
fever, the presence of a palpable sausage-shaped mass, tenesmus, and 
discharges of blood and mucus. 

Not infrequently a pneumonic process involving the base of the 
right lung causes pain which is referred to the ileocecal region, and 
the unwary may mistake this for appendicitis. 

Prognosis. — The tendency toward suppuration and the develop- 
ment of general peritonitis make this disease a grave one in early life. 
The mortality, however, will be distinctly lessened when early diagnoses 
are made followed by prompt surgical intervention. 

Treatment. — The medical treatment of appendicitis should con- 
sist in immediately placing the patient in bed, allowing him to assume 
a position of comfort. A light ice bladder is placed over the point of 
greatest tenderness. The bowels should be moved with a soap-suds 
enema. A liquid diet, consisting of milk, ice cream, and thin gruels 
is given if the vomiting permits. The question of operation should 
be left to the judgment of a competent surgeon. 

Children bear the operation well, and, unless the circumstances 
contraindicate it, immediate operation is to be preferred to the chances 
of perforation or general peritonitis. 



580 DISEASES OF CHILDREN. 

Intussusception. 

{Invagination). 

This very frequent form of intestinal obstruction in children is 
caused by a prolapse of a portion of intestine into the lumen of the 
adjoining bowel. 

While other causes, such as volvulus, Meckel's diverticulum, bands, 
and foreign bodies, may produce intestinal obstruction, they occur so 
rarely that they need not be considered here. 

Etiology. — We are inclined to believe that the condition can be 
accounted for by irregular peristaltic action taking place in a gut, 
the walls of which are thin and undeveloped and only loosely held by 
mesentery. 

The exciting cause may be undiscoverable. We have seen it in 
breast-fed infants who appeared healthy in every way. Overloading 
of the intestine, producing fermentation, colic and an irritative form of 
diarrhea may induce it. Constipation, tenesmus, polypi in the intes- 
tinal wall, appendicitis, and cathartic drugs have been held respon- 
sible for its onset. It occurs more frequently in males and the majority 
of cases occur in poorly nourished children in the first year of life. 
The fourth to the sixth month being the time of greatest incidence. 

Symptomatology. — The onset is sudden and acute in the majority 
of cases. Only in such situations as the rectum or low down in the 
colon may the symptoms come on at all gradually. An infant appar- 
ently healthy may suddenly begin to cry violently with pain which 
is usually regarded as colicky in nature, the extremities may be kept 
incessantly moving. Vomiting soon occurs, the child's appearance 
changes. The face is pale, showing marked evidences of distress and 
prostration. The first movement of the bowels after the intussuscep- 
tion may contain a single amount of fecal matter; thereafter the move- 
ments consist only of blood and mucus which are passed with some 
tenesmus. The vomiting which is almost projectile occurs at very 
frequent intervals. After the stomach contents have been emptied, 
bile-stained mucus or even fecal matter may be vomited in the final 
stages. There is little or no fever, but the pulse is extremely rapid and 
thready. On examination of the abdomen a sausage-shaped tumor 
may be felt, which if firmly palpated may feel harder. This tumor 
may be found in different situations, but generally is found in the left 
iliac fossa along the line of the colon. Bi-manual rectal examination 
may confirm its presence. In some instances it may protrude from 
the rectum and may be mistaken for a prolapse. It must not be for- 
gotten that intussusception can occur without the presence of a pal- 



THE COMMOXER SURGICAL DISEASES. 581 

pable tumor. Sometimes a depression or flattening in the opposite 
iliac fossa is observed. Unless relief is obtained the prostration be- 
comes more intense, subnormal temperature and death may ensue from 
exhaustion. Cases of spontaneous reduction and relief by gan- 
grenous sloughing of the intussusceptum have been reported, but are so 
rare as to merit recognition only as curiosities. 

Diagnosis. — This may be founded upon the following symptoms: 
A sudden onset, a paroxysmal colicky pain, vomiting, prostration, 
discharges of blood and mucus. 

In our experience dysentery is most often confounded with in- 
tussusception. The presence of some fecal matter in the stools, 
the constant fever, and the moderate vomiting with prostration only 
proportionate to the severity of the disease, should distinguish the 
conditions. 

Prognosis. — Unless the condition is promptly recognized and 
immediate treatment instituted, a fatal issue maybe expected. The 
mortalit}^ statistics vary from 60 to 70 per cent. The younger the 
infant the graver the prognosis. 

Treatment. — An attempt and only one should be made to reduce 
the intussusception if the diagnosis is quite certain within a few hours 
after the onset of the acute S3"mptoms. It may then be successful, 
especially if the invagination is in, the colon. 

The child is placed on its back, the buttocks elevated, and a warm 
saline solution from a two-quart fountain bag, held four feet above 
the patient, is allowed to distend the gut. The fluid should be retained 
by holding the buttocks firmly together. A long large catheter is 
preferable to the ordinary hard-rubber tip. "While the child is in this 
position gentle manipulations to assist the reduction may be made. 
If the result is successful the tumor disappears with a gurgling intes- 
tinal sound. Undue efforts in this direction should not be made. If 
reduction is unsuccessful or the case of longer standing immediate 
operative interference is demanded. A preliminary stomach washing 
and stimulation hypodermaticalh' in the form of strychnin or brandy, 
will better prepare the patient to withstand operative interference. 

Acute Peritonitis. 

In the New-born. — The diagnosis of the acute forms in infancy are 
too often made only at necropsy. This is so because of the uncom- 
monness of the affection, the meager history obtainable, if any, 
the lack of distinctive physical signs, and the inability of the patient 
to relate subjective symptoms. 



582 DISEASES OF CHILDREN. 

Fortunately, acute peritonitis is not a frequent occurrence among 
children, although in the new-born it is not as rare as it may be com- 
monly supposed. Through the umbilicus pathogenic bacteria may 
gain entrance and cause peritoneal infection. 

The streptococcus and the bacterium coli communis can be held 
responsible for the majority of the cases occurring in the new-born. 
When a general sepsis results the diagnosis is not as difficult as when 
the infection is localized in the peritoneum. 

Symptomatology. — In the new-born, the disease must be considered 
when there is a localized umbilical infection followed by a sudden 
abrupt change in the infant's condition. The extremely rapid gasping 
breathing may first attract the attention of the attendant. The in- 
fant cannot or will not nurse, the temperature is persistently high, 
104° to 105° F. with a rapid weak pulse. The position assumed by 
the infant is one of tension. Its legs are drawn up and pain is sharply 
elicited by attempts to even gently move the legs. The breathing if 
closely observed is seen to be mainly costal in type and extremely 
shallow. The distress caused makes abdominal palpation almost 
impossible. The constant rigidity encountered is quite characteristic. 
The urine is almost entirely suppressed. Pallor soon becomes marked, 
and death usually results in two or three days. 

In Early Life. — A similar train of symptoms occurs in the early 
years of life in peritonitis resulting from disease processes in other 
parts of the body as appendicitis, intussusception, perforation, trau- 
matism, strangulated hernias, lung involvement, or following the acute 
infectious diseases. Besides the streptococcus, we have the pneumo- 
coccus, gonococcus, colon bacillus, or the ordinary pus organisms as 
etiological factors. Pneumococcic and gonorrheal peritonitis are 
almost distinctively diseases of childhood. 

The diagnosis is likely to be obscured by the underlying affection. 
The medical attendant is likely to center his attention on the primary 
disease and is not attracted by the insidious train of symptoms 
in the abdomen. Invasion of the peritoneum is evidenced by sudden 
high increase of temperature, or a subnormal temperature with signs 
of collapse, extreme pallor, feeble rapid pulse, 120 to 180, and cold ex- 
tremities. The eyes are fixed and sunken, nausea and finally bile- 
tinged vomiting may follow. Any attempt to give medication or food 
by mouth is apt to be followed by vomiting. Constipation is the 
rule. The postural picture is the same as that just described 
for the new-born, except that a tympanitic condition is more apt 
to occur and the young child may feebly attempt to ward off any 
attempts at palpation of the abdomen. The pain may be referred 



THE COMMONER SURGICAL DISEASES. 583 

to the navel or localized in the iliac fossa. The leukocytes are 
moderately increased. 

Peritonitis of gonorrheal origin should be suspected where such 
a train of symptoms in a female child are accompanied by a specific 
vulvovaginitis. 

Pneumococcic peritonitis may result from any pulmonary disease, 
and especially from an empyemic process. It occurs here probably 
by direct infection through the lymphatics of the diaphragm. Hema- 
togenous infection seems to be the usual mode, since pneumococcic men- 
ingitis and abscess formations are not unknown. Since the exudation 
of pus is in this variety considerable in amount, the diagnosis is more 
readily made by the finding of accumulated fluid in the lower segment 
of the abdomen. If recognized early and proper measures of rest and 
posture are instituted, encapsulation is apt to occur, and the prognosis 
is correspondingly improved. Paroxysmal pains, chills, vomiting, 
severe diarrhea, and abdominal distention are noted in the early days of 
the disease. On palpation, there may be fluctuation, corroborated by 
dullness on percussion. Pneumococcic infection of the peritoneum, 
though a dangerous disease, is not necessarily fatal, as the pus may 
discharge through the umbilicus. If, however, surgical measures are 
not instituted at the beginning, rapid emaciation and prostration 
usually take place. Diffuse suppurative peritonitis maj^ then result, 
and a serious prognosis is inevitable. The diagnosis as to the exact 
form can only be made by examination of the pus which will show 
the presence of the diplococcus pneumoniae. 

Diagnosis. — The diagnosis in older children with a well-marked 
train of symptoms is not so difficult. In infancy it is often extremely 
puzzling and can often be made only by a process of exclusion. The 
symptom of pain cannot always be depended upon, as it is often rela- 
tively less than in adult life. 

From intestinal obstruction it is not always easy to differentiate 
peritonitis, but the lesser amount of abdominal tenderness, absence 
of fecal vomiting, and the passage of some gas or feces may be of as- 
sistance. It should not be forgotten that these conditions may be 
combined. 

Diaphragmatic pleurisy, or even pneumonia, when the pain is 
referred to the abdomen may occasion a mistake, if a complete physi° 
cal examination is not made. 

Prognosis. — In infancy it is invariably bad. In children peri- 
tonitis must always be regarded as a grave affection, although 
the encapsulated forms offer some little hope. If a perforation has 
taken place or if the process is general a fatal issue is to be expected. 



584 



DISEASES OF CHILDREN. 



The gonorrheal variety, especially in older children, has a better 
prognosis. 

Treatment. — An early diagnosis will be of value to the patient if 
prompt measures are taken to insure bodily and intestinal rest. If 
the case is seen very early, calomel or a saline may be given, before 
the application of an ice-coil. Paregoric for young children and 
codein hypodermatically for older cases will be required to alleviate 
the pain and to inhibit peristalsis. No attempt should be made to 
feed the patient. Pieces of ice or sips of ice-water to which brandy 
ha.s been added are grateful and often allay vomiting. Hypodermo- 
clysis and stimulants may be required for the pulse. 

The surgeon should be consulted as early as possible and decide 
as to the feasibility of operative interference. 

Ascites. 

By ascites is meant the condition produced by an effusion of 
serum into the peritoneal cavity. It may occur as a secondary condi- 
tion in peritonitis in any of its*varieties, in chronic nephritis and 
in certain blood diseases. Obstructions to 
the portal circulation, and chronic diseases 
of the heart and lungs may also produce 
ascites. 

Diagnosis. — The physical signs differ 
in nowise from those obtained in the adult, 
and therefore may be omitted here. 

Chylous Ascites. — The diagnosis of 
this rare form is made only after aspira- 
tion. Several cases have lately been re- 
ported. Its causation is unknown, but is 
attributed to some obstruction or disease 
of the thoracic duct. The ascitic fluid is 
milky white in color and usually contains 

fat globules in a fine emulsion. Leuko- 

, J r J 1,1 J n 1, Fig. 166. — Characteristic shape 

cytes and a few red blood-cells may be ^^ y^^^^^ -^ ^^^-^^^^ ^cabot) 

found. 

Treatment.- — Withdrawal of the fluid for the relief of pressure 
symptoms may be necessary in advanced cases, otherwise the treat- 
ment resolves itself into measures directed to the primary condition. 

Ischiorectal Abscess. 

These abscesses are more commonly observed in children of poor 
nutrition who have been reared under unhygienic circumstances. 




THE COMMOXER SURGICAL DISEASES. 585 

Through the lymphatic channels of the rectum, the perirectal lymph 
nodes become infected and form an abscess. The diagnosis is made 
on inspection or by rectal examination. 

Treatment. — Free incision, cleansing with antiseptic solutions, 
such as the peroxid of hydrogen and stimulation with a 2 per cent, 
silver nitrate solution, or packings saturated with balsam of peru and 
castor oil, one to ten, will effect a cure. In tuberculous children these 
abscesses may be exceedingly intractable and do not tend to heal until 
the general nutrition is improA'ed. 

Rectal Polypus. 

The growths are commonly found low down in the rectum and 
attached by a pedicle. Rarely are they multiple and sessile. On 
examination they are found to be adenomatous or fibromatous in 
structure. They vary in size, but rarely are larger than a hazel nut. 

Symptomatology. — The case is usually brought to the attention 
of the physician because of intermittent hemorrhages which may or 
may not be accompanied with tenesmus. Sometimes only the fecal 
masses are blood-streaked. If the straining is persistent prolapse of 
the rectum may result. Rectal examination is indicated with the 
above train of symptoms and the source of bleeding will then be found. 

Treatment. — The removal of the pedunculated tumors is easily 
accomplished by twisting the pedicle or passing a ligature about it 
before cutting it. If it cannot be withdrawn the use of an anesthetic 
and a speculum wiU be required so that bleeding from the stump may 
be arrested. 

Fissure of the Anus. 

This may occur following the passage of a hard constipated 
movement. It is also seen in children suffering from marasmus, 
syphihs, and eczema. Occasionally a fissure is produced by undue 
dilatation of the sphincter by injections, suppositories or rectal ex- 
aminations. Pain, some bleeding, and tenesmus are the signs which 
should lead to a careful inspection of the anal region. 

Treatment. — The buttocks should be separated as widely as pos- 
sible and the fissures touched daih^ with a solution of silver nitrate, 
dram one to the ounce. If constipation is present laxatives or enemas 
with careful OA^ersight of the diet will promote healing. In intractable 
cases the rectum should be gently dilated, a feat which is easily ac- 
complished in children by the successive introduction of well-greased 
fingers beginning with the smallest. This procedure should cause 
little or no pain, and generally effects a cure. 



586 DISEASES OF CHILDREN. 

Prolapse of the Anus and Rectum- 
Prolapse of the rectum is more commonly observed in children of 
the second and third years of life. The protrusion may be partial, 
being only a simple eversion of the mucous membrane, or complete, in 
which all the layers of the rectal wall protrude outside of the sphincter, 
sometimes for one or two inches. 

Etiology. — The causes provoking this condition are those accom- 
panied by much tenesmus, such as colitis, straining in chronic consti- 
pation or diarrhea, or with calculi. Rectal polypi will often lead to 
a prolapse. A neglected cause is the use of stooHng chambers too 




Fig, 167. — Adhesive plaster dressing for prolapse of the rectum. 

large to give proper support to the buttocks. Anemic and badly 
nourished children are particularly prone to this affection, as in them 
the pelvic musculature is incompetent. 

Symptomatology. — The protrusion of a dark red cone-shaped mass 
covered by transverse folds of mucus membrane, and with a rounded 
opening at the apex of the tumor is diagnostic. In some cases blood- 
streaked mucus soils the clothes. The mass can usually be readily 
replaced, but the protrusion will be apt to recur after straining or 
coughing or with the next defecation unless preventive measures 
are taken. 

Diagnosis. — Although the diagnosis is generally easily made, 
one of us has seen a mistake made in a case of intussusception in an 
infant in whom the invaginated gut protruded from the rectum. 

Treatment. — This consists in replacing the tumor and retaining 
it. A piece of gauze covered with vaselin is placed over the tumor, and 
by gentle pressure exerted over the entire mass the prolapsed tissues 
will slip back into place. If the reduction has been delayed too long 



THE COMMONER SURGICAL DISEASES. 



587 



it may be necessary to apply ice or ice-cold cloths for a short period 

and then to repeat the above manipulation. 

Two wide bands of adhesive plaster applied over the buttocks, 

above and below the anus, so as to exert firm pressure and give added 

support to the pelvic attachments, will retain the prolapse. Local con- 
ditions, such as constipation, colitis, 
and polypi, should be remedied and 
conditions of malnutrition cor- 
rected before a hope of permanent 
cure can be entertained. 

The child must lie on a bed- 
pan during defecation and the 
movement should be induced by 
a mild enema of oil or glycerin. 
He should be taught to avoid 
excessive abdominal pressure. 
Local applications of astringents, 
such as the fluid extract of kra- 
meria or tannic acid ointment, are 
helpful. The diet should be so 
regulated during the cure that the 
movements passed will be soft and 
unformed. Mild laxatives as cas- 
cara or the milk of magnesia may 
be necessary. 

In exceptionally severe or ne- 
glected cases, the prolapsing mu- 
cous membrane must be linearly 
cauterized by the thermocautery to 
produce cicatrix, or a radical oper- 
ation may be necessary. 




Fig. 168.- 



-Sarcoma of the lower 
abdomen. 



Malignant Tumors in Children. 

While almost any form of benign or mahgnant growth may occur 
in early life, it may be said that carcinoma is quite rare, while sarcoma 
is much more frequent. When this form occurs in children it is 
much more mahgnant than in adults. 

Three types are known, the round cell, spindle cell and giant 
cell varieties, the first being the most mahgnant. 

Nevi sometimes become sarcomatous, but the bones, kidney, testes, 
and epidermal tissues are more frequently involved. The ends of 
the long bones showing a special predilection. 



588 



DISEASES OF CHILDREN. 



Sarpoma of the face often causes confusion in diagnosis. Sarcoma 
of the kidney which is often congenital may attain an immense size. 
Their growth is exceedingly rapid and they are never bilateral. (See 
p. 491). 




Fig. 169. — Osteo-sarcoma of the temporal bone. 




Fig. 170. — Sarcoma of the face. 

Diagnosis. — The shape and size of the tumor is determined by its 
site and the tissues involved. The tumors are at first freely movable 
if located in soft tissues; they are seldom hard and firm; on the con- 



THE COMMONER SURGICAL DISEASES. 589 

trary, they may even feel fluctuant. Particularly suggestive are the 
superficial veins, usually dilated, which are found over these tumors. 
The skin covering them may be somewhat dusky or bluish in color. 

Metastases occur by way of the blood stream, consequently ad- 
jacent lymphatic glands are Hot involved. 

Treatment. — Sarcoma is of relatively rapid growth and ex- 
tension and this fact makes an early diagnosis essential, as complete 
removal is the only treatment. 



Fig. 171. — Sarcoma of kidney. 

Coley's fluid which contains the toxins of streptococcus, ery- 
sipelatosus and bacillus prodigiosus can be tried in inoperable cases 
with the hope of arresting the growth. It is administered hypoder- 
matically the injection being made into the periphery of the growth. 
Begin with injections of one minum, and as tolerance is produced the 
dose may be increased to five minims twice a day. 

In certain situations as on the face, considerable pain is experi- 
enced unless fairly powerful analgesics are given. 



SECTION XVI. 
DISEASES OF THE EAR AND EYE, 



CHAPTER XLII. 
DISEASES OF THE EAR. 

General Considerations. 

Familiarity with the anatomy of the organs and structures of 
hearing, at least in a general way, is incumbent upon those whose prac- 
tice is among infants and children. 

At birth the external bony canal has not developed and there is 
present only a cartilaginous canal. The walls of the soft meatus 
may in infants be found almost in contact so that the tympanic mem- 
brane is examined with difficulty unless these are separated. In 
structure the walls of the meatus are thicker than in the adult. The 
vault of the tympanum is disproportionately large and may have an in° 
complete tegmen. The Eustachian tube is shorter, horizontal, and 
relatively wider, the pharyngeal outlet being on a line below the hard 
palate. The mastoid process is entirely undeveloped at birth, and it 
is not until puberty that it assumes the adult characteristics. The 
antrum, however, is developed^ surrounded by thin bony walls. The 
close relationship of the sutures and the lateral sinuses to these struc- 
tures accounts, in greater part, for the frequency of intracranial com- 
plications in early life. 

Otoscopy. 

For this purpose a good light and a properly shaped speculum 
(see Fig. 172) is necessary. The child's arms should be fastened to its 
side by wrapping in a large sheet or towel; the attendant holds the 
child with one arm thrown about the chest and with the other on top 
of the head keeps the ear in the right direction. By drawing the auricle 
downward and backward a better view can be obtained. Accumula- 
tions of wax or exfoliations of the drum membrane must first be re- 
moved by the use of a fine cotton-tipped apphcator before a good view 
of the drum can be had (McKernon). 

590 



I 



DISEASES OF THE EAR. 



591 



If the ears of normal children are first examined the method and 
a working knowledge of the normal appearance "viil soon be obtained 
and otoscopy will then be more frequently made a part of the routine 
examination, and aural complications will go unrecognized less fre- 
quently, and more serious complications, such as mastoid involvement 
and deaf-mutism, prevented. The descriptions in this section are for 
diagnostic purposes and the reader is referred to books on this special 
subject for details of treatment. 



Fig. 172. — Properly shaped ear-speculum. 



Otitis. 

This is very common m early life, occurring almost always second- 
arily to the acute exanthemata, gastroenteritis, influenza, adenoid 
vegetations, and chronic rhinitis. Less commonly it may follow^ such 
diseases as typhoid infection, diphtheria, acute follicular tonsillitis, 
and cerebrospinal meningitis. It may also be induced by improper 
methods of nasal irrigation or by violently blowing the nose; the 
bacteria in the nasopharynx being forced into the Eustachian tube. 

According to Liebman, the streptococcus is most frequently found 
(52 per cent.), streptococcus mucosus next in frequency (8 per cent.), 
then the pneumococcus (6 y\ per cent.). 

Symptomatology.- — Unfortunately, in many instances otitis occurs 
during the course of an illness, as, for example, in measles, and unless 



592 DISEASES OF CHILDREN. 

daily otoscopic examinations are made^ the first intimation of the proc- 
ess is a discharge from the external ear. If after the acute symptoms 
of the primary disease have subsided a sudden and rather constant 
elevation of temperature, with and frequently without earache, occurs, 
otitis should be suspected. In some cases rupture takes place even 
without elevation of temperature. When in infants there is restless 
sleep with sudden unexplainable outcries, pulling at the ear, with 
pyrexia higher at night, inflammation within the ear should certainly 
be thought of. Older children who are able to localize and speak of 
their pain describe it as '^stinging" in character. The pain comes 
on at intervals and is worse toward evening and during the night. 
Otoscopic examination in these cases will disclose a much reddened, 
swollen, or bulging membrane. If the process has not advanced to 
the point of actual suppuration there may only be found a crescentic 
area above ShrapnelFs membrane with absence of the normal shining 
appearance of the lower half. 

If the perforation has occurred, the opening is usually seen in the 
posterior and lower quadrant. The discharge may be serous, sero- 
purulent, or purulent in character. Chronic otitis media, sinus throm- 
bosis, and meningitis sometimes follow. In most of the cases, how- 
ever, following spontaneous rupture or incision of the membrane the 
discharge after a time ceases, healing takes place and restitution to 
normal occurs, often with little or no disturbance to the hearing. 

Treatment. Prophylactic. — Daily examination of the tympanum 
in the course of the acute infectious diseases, the removal of adenoid 
growths and hypertrophied tonsils, and the inculcation of habits of 
cleanliness, such as the nasopharyngeal toilet (see p. 87), will do 
much to prevent the involvement of the ear. 

General. — Early incision of the drum membrane should be 
practised in the acute cases if the condition of the membrane warrants. 
Hot irrigations of saline solution at 110° F. with a fountain bag held 
two feet above the ear, give considerable relief, and in the milder cases 
the symptoms may entirely subside under this form of treatment. 
Chronic conditions require copious irrigations with a warm solution 
of (1-10,000) of bichlorid of mercury several times a day. It is best 
to refer these cases to the specialist for more radical treatment if they 
do not show improvement after a few weeks. 

Mastoiditis. 

This most frequently results as a complication of acute or chronic 
middle-ear suppuration and the same etiological factors as given under 
the article on Otitis concern us here. The anatomical structures as 



DISEASES OF THE EAR. 593 

outlined in the general consideration and the greater tendency 
toward necrosis of bone in early Hfe favor the involvement of the 
mastoid process. 

Symptomatology. — The symptoms appear after a variable time 
during the convalescence following an artificial or spontaneous rupture 
of the drum. A sudden or gradual pyrexia may be the initial symptom. 
This, as a rule, is not high, but continues several days, reaching its 
highest point in the evening. Otoscopy, if there has been a previous 
perforation, may show a decrease in the amount of discharge, but the 
pus may show that some retention in the deeper structures has taken 
place by appearing in drops after cleaning the canal. Sometimes 
there is seen prolapse and bulging of the superior and posterior por- 
tion of the canal wall. Restlessness with frequent periods of crying, 
especially at night, is present in most of the cases. Occasionally the 
temperature reaches 104° or 105° F. in the evening, and the lymph- 
glands in the neighborhood are swollen. The tissues over the mastoid 
may become edematous and the auricle is pushed out from the scalp. 
In unrecognized cases a perimastoid collection of pus takes place, 
especially in infants, and pressure over this tumefaction causes a dis- 
charge of the pus W' hich has collected in the external canal. Meningeal 
symptoms may appear or in neglected cases the cerebral symptoms 
may predominate and obscure the diagnosis. 

Treatment. — An early diagnosis is imperative in mastoiditis, 
for it is onty b}^ the radical operation which drains the middle ear that 
the mortality in this serious disease may be low^ered or more serious 
complications, as infection of the jugular bulb, avoided. 

Infective Cerebral Sinus Thrombosis. 

(Jugular Bulh Infection.) 

The most frequent cause of local infection of the cerebral sinuses 
is suppuration in the middle ear and mastoid cells. A general sep- 
ticemia as a result of aural complications may also produce sinus 
thrombosis through the general circulation. Streptococci are most 
frequently found to be the direct cause of the infection. 

Symptomatology. — The disease should be considered if there is 
a sudden rise of temperature in a patient who has a discharge from 
middle-ear disease. This fever is extremely irregular, septic in charac- 
ter, rising often to 105° or 107° F., with remissions to the normal or sub- 
normal. The pulse rate is correspondingly high, the infant is at first 
highly irritable and restless and soon becomes apathetic and finally 
stuporous. There may be evidences of meningeal involvement. 

38 



594 



DISEASES OF CHILDREN. 



vomiting and convulsions occasionally occur. If the disease has re- 
sulted from the mastoid there may be edema in this region, and per- 
haps, a clot in the jugular vein. The percentage of polynuclear ele- 
ments is high, ranging from 80 to 90 per cent. 

Prognosis. — This is extremely unfavorable. A fatal issue usually 
results in a few days unless operative interference is successful. 

Treatment. — Early diagnosis followed by prompt operative pro- 
cedure is the only recourse. Recent reports show encouraging results. 




Fig. 173. — A servicable electric auroscope. 



CHAPTER XLIIl. 

THE COMMONER DISEASES OF THE EYE. 

. Foreign Bodies. — Foreign bodies are frequently caught under the 
eye-lids of children, and if not washed away by their own tears which 
are usually copious, they should be quickly removed to prevent in- 
flammatory changes. The upper lid can be everted easily if the child 
is prone and correctly held to prevent interference. The foreign sub- 
stance can usually be easily removed by a fine probe, the end of which 
has been wrapped with a few strands of absorbent cotton. Metallic 
substances may require local anesthesia, which is accomplished with 
two drops of a 2 per cent, solution of cocain. If the particle is not 
readily removed, the patient should be referred to a properly equipped 
ophthalmologist. 

Blepharitis. — This is often observed in tuberculous, anemic, or 
poorly nourished children, especially when they have a dermatitis 
elsewhere on the body. The secretion as it dries produces further 
excoriations and aggravates the trouble. Treatment should be directed 
to the general condition, improving the nutrition by proper diet, cod- 
liver oil and iron tonics for the anemia. General cleansing baths daily 
with bicarbonate of soda will prevent reinfection. Locally, the eye- 
lids are bathed with a 2 per cent, boric acid solution until all the 
crusts are removed and applications of an ointment of yellow oxid of 
mercury (1-100) are then made morning and night until a complete 
cure is produced. 

Conjunctivitis — Acute. — Injuries and the infectious diseases pro- 
duce acute inflammations quite readily in children and the mucoid se- 
cretions are apt to be more profuse than in adults. The eye-lids should 
be gently separated and the secretions flushed out. Microscopical 
examination of a purulent secretion should be made to determine the 
possibility of infection by the Klebs-LoefHer bacillus or thegonococcus 
of Neisser. A careful search should be made for foreign bodies. If 
there is no secretion, applications of a 2 per cent, warm boric acid solu- 
tion every fifteen minutes may suffice for a cure. If the secretion is 
purulent, argyrol in 12 per cent, solution may be ordered or silver 
nitrate (1-100) may be applied by the physician and quickly flushed 
out with sterile salt solution. Ice-cold applications are often necessary 
and should be freshly applied every ten minutes until the inflammation 

595 



596 DISEASES OF CHILDREN. 

subsides. A drop of atropin sulphate (1-200) may be necessary two 
or three times a day to procure rest for the eye. 

Diphtheritic. — The membrane is tenacious, with an absence of 
secretion and much exudation and edema in the eye-hds. The ex- 
treme rapidity of the involvement and the presence of a possible nasal 
diphtheria should excite suspicion. The treatment is that of diph- 
theria elsewhere. An injection of 5,000 units of antitoxin should be 
given, and locally the eye should be flushed with boric acid solution 
and kept cold with ice compresses. Protecting the sound eye from 
infection may be accomplished by the use of a shield or the instillation 
of a 25 per cent, solution of argyrol every two hours. 

Chronic. — A careful examination for ocular defects should always 
be made in these cases and the child's habits as to study, etc., inquired 
into. Not infrequently the condition is improved by appropriate 
general treatment or a change from urban to rural life. Locally, 
astringent applications of zinc sulphate (1-250) or silver nitrate 
(1-500) may be made by the physician several times a week and one of 
the organic silver salts supplied for home use, as argyrol in ten per cent. 
solution one or two drops, twice a day. Internally the syrup of the 
iodid of iron is often of assistance. 

Trachoma {granular conjunctivitis). — Routine examination of 
the school children in New York City has brought to light many cases 
of chronic conjunctivitis which are classed as trachomatous. The 
condition occurs in several children of a family and certainly appears 
to be of a microbic nature. Ordinarily the type seen is mild in charac- 
ter and is often classed as a granular conjunctivitis. The heaped-up 
granulations and deposits are plainly seen when the lids are pulled 
down. The upper lid should also be everted and examined. Mar- 
ginal ulcerations may occur if the disease is allowed to run its course 
untreated. 

Treatment is proportionate to the severity of the condition. 
Prophylactic measures to protect other children in the family and 
school should be insisted upon, such as individual towels and wash cloths. 
Constant supervision and treatment will finally eradicate the con- 
dition and lessen the host of cases now in our schools. 

Locally, a solution of zinc sulphate (1-250) or the cupric stick 
may be used by the physician several times a week on the granulations, 
and a solution of bichlorid of mercury (1-5000) or argyrol 10 to 20 
per cent, may be ordered for home use, one drop being instilled twice 
a day in each eye. Severe cases will require the expression operation 
with forceps under a general anesthetic. 

Chalazion. — A chalazion is a cyst which results from retention 



THE COMMONER DISEASES OF THE EYE. 597 

products of the Meibomian glands. There is rarely any pain, although 
discomfort is complained of by older children. They are generally 
excised if they tend to recur. 

Hordeolum or stye is found on the margin of the eye-lid and acts 
like a furuncle on any other part of the body. The evacuation is 
hastened by hot applications and early incision. 

Strabismus. — Strabismus (squint) may be either paralytic or non- 
paralytic. Paralytic squint is due to partial or complete paralysis of 
one or more of the muscles of the eye. It may be congenital, or it 
may be acquired from trauma or from an acute infectious disease, 
such as diphtheria or cerebrospinal meningitis. It may also result 
from photophobia, phlyctenular keratitis, and interstitial keratitis. 

Non-paralytic squint in children is more common, and it is usu- 
ally convergent. Contrary to a common belief, children seldom 
''grow out " of it. If neglected, the squinting eye usually becomes am- 
blyopic. Neglected ''cross eyes" are responsible for many blind eyes 
in adults. If prescribed sufficiently early, correct glasses accomplish 
cures in many of these cases. Even young children can wear glasses 
without danger. 

Keratitis. — This is usually found in tuberculous and rachitic 
children, secondary to other ocular and dermal conditions, although 
syphilis itself causes the interstitial or parenchymatous variety. 

The condition begins with congestion and involvement of the 
tissues about the cornea. There is photophobia, orbicular spasm, 
pain, and an abnormal flow of tears. Later a haziness is observed and 
vision is impaired. The superficial lesion, if untreated, soon invades 
the cornea, and ulceration or even suppuration results. 

The phlyctenular variety is most frequent in early life. Begin- 
ning with small vesicles on the palpebral conjunctiva, it spreads to the 
ocular conjunctiva and here forms characteristic ulcerations w^hich 
may leave permanent opacities of the cornea. Treatment should 
be directed to the underlying constitutional condition. The inter- 
stitial form generally reacts to antisyphilitic treatment. Children 
poorly nourished or badly housed must be removed to hygienic 
quarters to effect a cure. Good food, fresh air, and baths add greatly 
to the possibilities of local treatment. Any fissures in the angles 
should be treated with silver nitrate solution (dram one to the 
ounce), followed by a flushing with normal saline. 

Placing a shade over the eyes is preferable to a darkened room for 
the child. Bathing with hot boric acid solution three or four times 
a day is soothing and helpful. An ointment of yellow oxid of mercury 
(1-100) may be supplied for use on the eyelids at night in phlyctenular 



598 DISEASES OF CHILDREN. 

keratitis, and an ointment of bichlorid of mercury (1-5000) applied 
for the other varieties. A solution of atropin sulphate (^ per cent.) 
may be necessary in some cases to give rest until the child responds 
to the general treatment. 

The Diagnostic Significance of Ocular Affections. 

The eye may so often be of assistance in establishing a diagnosis 
that a short article will be devoted to the interpretation of certain 
ocular lesions or manifestations. 

Every physician should be prepared to make certain simple tests 
in his office to discover ocular defects in the routine examination^ 
and the eyes should be examined even when the patient is not presented 
for defective eye-sight. In this way he may find the cause for back- 
wardness in school studies, headache, and dizziness. Of still greater 
importance is the fact that recognizing unsuspected deficiencies in 
visual acuity he will refer the child to an oculist for more rigid and 
detailed tests and correction of refractive errors while the eye is still 
in the formative period. All that is required for these tests is a 
Snellen's test card, a picture card for children unable to read, a candle 
placed at twenty feet and the multiple rod of Maddox for testing the 
functional balance of the ocular muscles. 

Valk has shown that the Americans as a nation are found to be 
far-sighted with astigmatism. There is no doubt that many of the 
children of this generation suffer from overuse of their eyes because 
of the competition of school life and the multiplicity and cheapness 
of all forms of reading matter to which they have unrestrained access. 

Parents must be warned of these conditions and prophylactic 
measures advised to protect the vision of their children so that arti- 
ficial aid may not be required. The study room should be well-lighted 
and ventilated, with the desk or table so placed that the light will 
come over the left shoulder. The use of vertical writing is to be com- 
mended. Reading in the recumbent position or during convalescence 
should be prohibited. Badly printed books should not be tolerated 
in these days of modern printing. 

Diagnostic Hints. 

Ptosis as seen in children is usually a congenital defect as lesions 
of the oculomotor nerve are exceedingly uncommon in childhood. 

Photophobia is not uncommon and usually indicates some in- 
flammatory affection of the structures of the eye, for example, corneal 
ulceration. It does not usually occur with conjunctival diseases. 



THE COMMOXER DISEASES OF THE EAR. 599 

Exophthalmos, or prominence of the eye-ball, is sometimes seen in. 
older children who have the symptoms of goiter. 

Diplopia indicates paralysis of any of the straight ocular muscles, 
and it may result from any cause which will prevent both eyes being 
fixed on the same point. The form varies with the muscle affected. 
It is sometimes a symptom in hereditary ataxia. 

Strabismus appearing suddenly, convergent in character and 
accompanied with diplopia, is one of the signs of basilar meningitis. 
It may also be seen in hysteria, but here is functional only in character. 

Nystagmus, or the rapid oscillations of the eye-balls, may be lateral, 
vertical, or rotary movements. It usually is bilateral. It rarely 
occurs congenitally, and is then without serious significance. It is 
observe-j :n many cerebral diseases, especially those associated with 
congenital detects, in disseminated sclerosis, and in Friedrich's ataxia. 
Tumors of the cerebellum or pons may produce this ocular symptom. 
It is sometimes seen in the later stages of hydrocephalus. 

Optic Neuritis (Choked Disk), Papillitis. — This condition may 
be found on ophthalmoscopic examination and indicates some form of 
intracranial lesion or affection of the orbit. Papillitis is seen in 
meningitis, particularly of the tuberculous variety; sometimes it occurs 
with tumor and abscess of the braiuu 



SECTION XVII. 
DISEASES OF THE SKIN, 



CHAPTER XLIV. 
DISEASES OF THE SKIN. 

Introduction. 

Diseases of the skin form a very important part of tlie affections 
of early life. In infants this is particularly true owing to the hyper- 
sensitiveness of the skin which is suddenly bereft of its covering 
of vernix caseosa at birth and exposed to irritants of varying degree 
either from without or from within. It must also be recollected that 
faulty metabolism will account for many of these skin lesions. Young 
protoplasm is very irritable, and hence comparatively slight causes 
may produce severe lesions of the skin. 

The causative factor should be carefully sought after in each 
case and treatment should be directed not alone to the local lesion, but 
to the systemic condition as well. When prescribing local treatment 
the tenderness and sensitiveness of the infantile epidermis should not 
be forgotten. Better and more permanent results are obtained if 
soothing and unirritating drugs are employed and if the skin is pro- 
tected from further injury by prevention of scratching or further in- 
fection. The latter condition often masks the nature of the original 
disease, hence the most recent lesion must always be sought for 
diagnostic purposes. 

A certain number of skin diseases are congenital or are seen mainly 
in infancy. These will be mentioned first and then the commoner 
diseases met with in the early years of life, and finally those seen for the 
most part in the school age. 

Ichthyosis. 

{Xerodermia) . 

Ichthyosis or fish-scale disease is regarded as a congenital skin 
affection, mainly transmitted by heredity. It is characterized by a 
dry scaling condition of the skin whose outer layers are hard, dry, and 
thickened and without any inflammatory phenomena. Several mem- 
bers of a family may be affected. 

600 



DISEASES OF THE SKIN. 



601 



Symptomatology. — The whole body, as a rule, may be covered with a 
scaling, wrinkled, papery skin, especially on the outer surfaces of the 
arms and legs. In the flexures of the joints fissures are sometimes, 
formed. The general health remains unaffected. Irritants easily 
cause pruritis and local inflammatory reaction. 

Diagnosis. — The disease is rarely mistaken on account of its dis- 
tinct characteristics. The history and its non-inflammatory charac- 
ter would distinguish it from trophoneuroses or pityriasis. 

Prognosis. — It is an intractable disease requiring long and patient 
treatment to affect any amelioration. It is never really cured. 




Fig. 1.4. — Pigmented nevus. 

Treatment. — If the treatment is begun in early infancy much 
more can be accomplished than when seen later. Baths of green 
soap followed by inunctions of lanolin or vaselin and protection of 
this greased surface with gutta percha tissue, later a 5 to 10 per cent, 
sulphur ointment can be applied. Life in the tropical countries is 
favorable to comfort and possible cure. 



Nevi. 

These congenital growths may be vascular or pigmented (moles). 
The latter may also be hairy or rough and warty. The color varies 
from a light brown to black. Vascular nevi are due to local excessive 
proliferation of blood-vessels at or soon after birth. These disfigure- 



602 DISEASES OF CHILDREN. 

ments are found for the greater part in the corium, and vary from the 
famiUar port-wine stains to pulsating angiomata. They are apt to 
increase in size soon after birth and do not grow beyond certain hmits. 

Prognosis. — Vascular nevi of the cavernous type may be danger- 
ous to life because of the danger of bleeding or from their effect on 
neighboring structures. Pigmentary nevi have shown metamorphic 
changes into later growths of a malignant character. 

Treatment. — This is accomplished by electrolysis or cauterization 
acting upon the corium only. Radiotherapy occasionally is success- 
ful. Excision offers the best results; occasionally skin grafting is 
necessary following excision of large nevi. A needle may be heated 
to a cherry-red color and plunged into the margin at three or four 
points. This may be repeated at subsequent sittings until the nevus 
has been entirely eradicated. A white scar remains over the site. 
Ice made from liquid carbon dioxid is often suitable for the removal 
of port-wine stains or superficial nevi. 

Dermatitis Exfoliativa Neonatorum. 

(Ritter's Disease.) 

Badly nourished infants, usually nurslings, are affected by this 
disease. It is quite rare. It begins, as a rule, on the lower half of the 
face as a reddened area with exfoliation. This erythema soon spreads 
over the entire body and the resulting scaling is profuse. Fissures ap- 
pear at the mouth and anus. Constitutional symptoms are those of 
malassimilation or, in severe cases, those of sepsis. Even when resti- 
tution to the normal takes place after patient and diligent treatment, 
relapses are not uncommon. Hitter gives the cause as a general sepsis. 

Course and Prognosis. — The two cases coming under our observa- 
tion in hospital practice both died. The mortality is 50 per cent. 
Occurring as they do among the poorer classes, medical attention is 
not drawn to them until the vitality has suffered beyond repair. 

Treatment. — Maintain the body heat by the use of lanolin and 
such clothing as is recommended for the premature (see p. 2). Care- 
fully examine the breast milk, and if abnormal a wet-nurse may be 
indicated. Strychnin in doses of gr. -g-g-g- every two or three hours 
is given if the vitality is low. 

Pemphigus Neonatorum. 

This is a contagious skin disease characterized by the formation 
of bullae containing a purulent fluid. No specific microorganism has as 
yet been isolated. The large vesicles or bullae may suddenly make 



DISEASES OF THE SKIN. 



603 



their appearance on any part of the body causing Uttle or no systemic 
disturbance. The blebs vary from transparent to grayish forms. The 
distended vesicles may rupture, leaving a crust and a reddened base, 
but no scar formation results. The exudate may infect new areas or 
even those in contact. The disease usually runs a favorable course 
tending to complete recovery in a few weeks. They should be differ- 
entiated from the bullous syphilo- 
derm, sometimes called syphilitic 
pemphigus, which occurs mainly on 
the soles of the feet and palms of the 
hands with usually an ulcerated base, 
and is accompanied with other mani- 
festations of infantile syphilis. 

Treatment. — Evacuate each bleb 
carefully by pricking w^ith a sterile 
needle and apply zinc stearate for 
desiccation. A daily bath in a solu- 
tion of bichlorid of mercury (1-10,000) 
is indicated if self -inoculation is evi- 
dently going on. 



Impetigo Contagiosa. 

This skin disease usually attacks 
the face at the corners of the mouth 
and nostrils, although any portion of 
the body may exhibit the lesions. 
These consist of grayish-yellow sticky 
crusts which have a honey-like dis- 
charge. They are seated upon a red 
base. The child eagerly picks at these 
crusts and infects other areas. 

Treatment. — The general health, 
if deficient, will require proper feed- 
The crusts are softened by green-soap 




Fig. 175. — Impetigo. 



ing — iron or cod-liver oil. 

poultices and removed. The areas are then covered with benzoated 

lard or lanolin with bichlorid of mercury gr. i to the ounce. 

Seborrhea Capitis. 

Overactive sebaceous glands produce a crust of sebum which 
soon becomes dry and scaly. It commonly occurs upon the scalp 
and forehead in infants, and is known by the laity as " milk crust." 
It is a dirty yellow, firmly adherent mass lying upon an uninflamed 



604 DISEASES OF CHILDREN. 

surface. It is more commonly found in poorly nourished children 
than in lusty breast-fed babies. 

Treatment. — Attention must be given to the general nutritional 
requirements together with local applications of warm olive oil or boric 
acid ointment (10 per cent.) under an oil-silk cap. Applications of the 
ointment are made twice a day, until finally the crust has softened. 
They are then removed with a superfatted soap or a glycerin soap and 
the scalp annointed daily for a time with a 2 per cent, sulphur ointment. 

Erythema Multiforme. 

This is an acute inflammatory disease, in which are variously 
produced areas of erythema, macules, papules, or vesicles. Some 
constitutional disturbance may usher in the attack. This is usuahy 
mild in character; there may be fever and malaise with or without 
rheumatic pains. The lesions, as a rule, appear on the extensor sur- 
faces of the hands, arms, feet, and legs. The face and upper chest are 
often involved, although any part of the body may exhibit the erup- 
tion. The color varies from a light red at first to a deep red in older 
lesions. Only occasionally are hemorrhagic areas seen. Pruritus, is 
not a marked symptom. Accompanying the erythema in children 
there are usually observed symptoms of intestinal derangement, 
autointoxication, ptomain poisoning, etc., which have undoubtedly 
produced this external manifestation. The disease is liable to recur- 
rence, lasting as a rule, for a few weeks before subsiding. 

Treatment. — This should be mainly directed to the underlying 
viceral derangement. An initial purge is indicated in the form of 
calomel or castor oil. A careful history of the child's diet will nearly 
always disclose some radical fault which needs correction. A specially 
arranged dietary should be provided. The emunctories should be kept 
active. Locally, if there is pruritus, an ointment containing resorcin 
or acid carbolic may be applied. 

Acute Exfoliative Dermatitis. 

This condition is of interest because of the confusion which it 
may cause in children from its resemblance to scarlatinal infection. 

Intestinal toxemia will commonly be found to be the underlying 
cause. Following an erythema of the scarlatiniform type, in a few 
days or sometimes hours, there occurs a profuse exfoliation. Con- 
stitutional symptoms are more pronounced than in scarlatinal ery- 
thema. The exfoliated scales of large and papery strips are cast off 
(see Fig. 8, Plate IX). The hair and nails may drop out before the 



DISEASES OF THE SKIN. 605 

process is complete. Furnuncles and pustules are sometimes en- 
grafted on the dermatitis with involvement of the neighboring 
lymphatic glands. 

Diagnosis. — The differential diagnosis in the erythematous stage 
and in that of exfoliation is given under the article on Scarlet Fever 
(see page 260). 

Treatment. — Correct the toxemia by unloading the intestine and 
prescribing a diet that will not cause fermentation. Repeated 
examinations of the urine for indican will assist in properly meeting 
this indication. Fowler's solution with iron is of value after the 
dietary error has been corrected. A 2 to 5 per cent, ichthyol ointment 
is soothing to the skin. The cure is slow and recurrences are frequent. 
The exfoliation may occur two or three times a year. 

Eczema. 

{Tetter; Salt-rheum.) 

This is a protean disease of unknown origin assuming an acute, 
subacute, or chronic course, characterized by an erythematous eruption 
of varying intensity which goes on to scaling or crusting and is asso- 
ciated invariably with marked pruritus. 

It is the most common of all the skin diseases observed in early 
life. 

Etiological Factors. — Irritants either of external or internal origin 
or both are responsible for the affection. Children who have nutri- 
tional or blood disorders are particularly susceptible. The usual 
pyogenic bacteria found on the skin are no doubt responsible in- 
directly for many cases. Their growth is facilitated or increased by 
mechanical or chemical irritants with which the child comes into 
contact. The so-called "predisposition" to the disease is often 
accounted for by careful investigation for the cause along the lines 
above enumerated. Parasitic skin diseases, discharges from various 
parts of the body, badly prepared soaps and powders, and irritating 
underclothing are among the more common external causes. Excess- 
ive feeding, in general or in kind, and constipation are the prominent 
internal causes. 

Varieties. — Depending upon the degree of the exudative inflam- 
mation in the epithelium, there is produced an erythematous, papular , 
vesicular, or pustular eczema. 

These forms either remain distinct or merge one into the other, 
somewhat masking the original type. The erythematous variety is 
characterized by redness and swelling over certain areas, especially the 



606 



DISEASES OF CHILDREN. 



face. The papular type is known by the formation of small red pap- 
ules which tend to group and coalesce. In the vesicular phase the 
upper layers of the epidermis are raised by the exudative process, form- 
ing vesicles or blebs which tend to coalesce and exude a viscid serum. 
These, however, are evanescent and are rarely seen because they are 
rapidly dissolved off, leaving a wet surface. If the latter form becomes 
infected by pyogenic skin bacteria or over- 
loaded with leukocytes the pustular form 
develops. 

Sub-varieties. — When the discharge 
in the vesicular form dries readily it forms 
crusts (E. crustosum). If the exudation is 
profuse and the rete is uncovered, the 
weeping or moist form results (E. madinans 
vel rubrum). A squamous variety is 
superimposed or develops from the crusty, 
papular, or vesicular form when consider- 
able epidermal infiltration and scaling 
appears. 

Chronic Varieties. — These result 
from repeated recurrences, or exacerba- 
tions, or neglect of the etiological factors. 
The chief characteristic is the infiltration 
into the upper layer of the skin. 

Symptomatology and Diagnosis. — All 
the varieties described above have certain 
common features, namely, redness, itching, 
and burning, accompanied by the forma- 
tion of papules, vesicles, or pustules. The 
skin being either dry, moist, infiltrated, or 
scaling. In infants the scalp, face, and 
napkin region are most frequently attacked. 

The diagnosis is, as a rule, not difficult if the above description and 
classification is kept in mind. Erysipelas is distinguished by the 
rapidly spreading margin and high fever. Scabies is often confounded 
with eczema or the two are combined. The distribution and the itching 
which is worse at night, the history of the other children or members 
of the family similarly affected, or the burrows and their contents 
themselves can be depended upon to estabhsh the diagnosis. Psoriasis 
is rare in early life; it is never moist, it is commonly found upon the 
elbows and knees and has silvery scales. Syphilides occasionally are 
difficult to distinguish. The infiltration is deeper and greater; they 




Fig. 176. — Chronic eczema. 



DISEASES OF THE SKIN. 



607 



do not burn or itch and are usually accompanied by other manifesta- 
tions. In difficult cases the Wassermann test may be employed. Im- 
petigo contagiosa has discrete vesicles upon slightly reddened skin, 
with abrupt margins. They are contagious and the child easily 
inoculates itself in different parts of the body. 

Prognosis. — This is variable, depending upon the underlying 
cause and the time of instituting treatment. Acute cases are favor- 
able but the chronic varieties are often intractable and persist with 
exacerbations and recurrences for years. 




Fig. 177. — Child with eczema fitted with metallic glove to prevent scratchmg. 



Acute Eczema. — Treatment. General. — The underlying cause 
should be carefully sought for and removed. If this is accomplished 
the cure will be well under way. Especially important is the proper 
regulation of the diet. If there is present such a condition as 
rickets, marasmus, or anemia the diet must be so arranged 
as to overcome the nutritional disorder. Cod-liver oil is often 
helpful. If, on the other hand, there has been overfeeding or indul- 
gence in special articles as the sugars or potatoes, such indiscretion 
must be stopped. The constipation should be relieved by correct- 
ing the diet or adding thereto such articles as fruits, the drinking 



608 



DISEASES OF CHILDREN". 



of plenty of water and appropriate massage and exercises. In in- 
fants the milk of magnesia may be added to the milk for its laxative 
effect. 

Local. — Never allow soap or water to be used on any eczema- 
tous surface. Cleansing can be satisfactorily accomplished with olive 
or linseed oil. The irritated skin must be treated by bland, soothing 
ointments or powders and scratching absolutely prevented. Rest 
for the inflamed area is imperative. 
Scratching is prevented by the use of 
masks, bandages, or sleeves as shown 
in the illustration (Fig. 178). 

The mild cases of the erythem- 
atous, papular, or moist types may 
be dusted with stearate of zinc, car- 
bonate of magnesia, oxid of zinc, or 
boric acid. • 

In the inflammatory stages 
lotions of 2 per cent, boric acid, cala- 
min, or a 1 per cent, solution of 
aluminum acetate are applied as moist 
dressings. These soothe and reduce 
the inflammation. Occasionally small 
areas of weeping eczema may be 
rapidly improved by the primary ap- 
plication of h per cent, solution of the 
nitrate of silver. Among the oint- 
ments, Lassar's paste (N. F.) has given 
us the best results. It is applied 
thickly over the inflamed area and a 
retaining bandage or mask is applied. 
If thick crusts are present these must first be removed with applica- 
tions of olive oil or boric acid ointment. The dressings are removed 
daily, the ointment carefully removed with absorbent cotton dipped 
in oil and the ointment reapplied. 

Subacute Eczema. — If for any reason treatment has been delayed 
or has been unsuccessful in the acule stage more stimulating applica- 
tions are necessary. The amount of oxid of zinc in the pasta Lassar 
(N. F.) may be increased, and small amounts of tar in the form 
of tincture picis hquidse may be added, or the following may be used: 

I^. Picis liquidse 3ss 

Sulphuris prsecipitati o.j 

Unguenti zinci oxidi • • • oij 

Misce et signa. — Apply morning and evening. 




Fig. 178. — Eczema mask with stiff 
sleeves to prevent scratching. 



DISEASES OF THE SKIN. 609 

The same precautions must be observed to prevent scratching or irri- 
tation of the area and the diet and bowels regulated. 

Chronic Eczema. — Perseverance and careful watchfulness as to the 
action of the drugs used in this form will be necessary to effect a cure. 
The thick crusts must first be removed by applications of oil, boric 
or bismuth ointment. Stimulating ointments are then to be used. 
The majority of children bear the ointments well, but occasionally 
they are not w^ell tolerated and stimulating lotions or baths must be 
substituted. Tar is added in greater proportion to the ointments w^hich 
have been recommended above. The tincture picis liquidse or the 
liquor carbonis detergens act advantageously by producing stimula- 
tion and at the same time preventing itching. If large areas are 
affected, it is w^ell to apply the tar ointment to limited portions of the 
skin first and observe its effect. After it has produced an acute reac- 
tion, the milder pastes are applied. 

Psoriasis. 

Psoriasis among the skin affections is quite commonly observed 
in apparently healthy children. It begins as a papular affection with 
silvery scales on their summits. Their growth causes the commonly 
observed irregular patches with well-defined edges, of a bluish-red 
color, somewhat raised above the surrounding skin. Invariably 
silvery scales are found in these plaques which can be readily removed, 
leaving a reddish glazed base. The extensor surfaces of the extremi- 
ties are the favorite seats, next to the trunk and scalp. The affection 
is a chronic one with a great tendency to return in spite of well-directed 
treatment. Spontaneous cure in the summer months is not 
uncommon. 

Treatment. — Bulkley emphasizes the dietetic treatment and as 
the youthful patient is apt to be indiscreet, this should be the first 
consideration. A vegetarian diet may be appropriate for the child 
with a rheumatic history, although obviously unfitted for an anemic 
child below weight. Outdoor life at the seashore wdth sea-bathing 
is productive of much good. As soon as the lesion appears an applica- 
tion of green soap and a full bath are ordered to remove the super- 
ficial scales. A crysarobin ointment is applied to a small area in 
the strength of 5 to 10 grains to the ounce (except to the face) tw^ice 
a day until the skin is clean. Latterly X-ray treatment has produced 
rapid results. Warning should always be given as to its liability to 
return and the importance of renewing the treatment early. 

39 



610 DISEASES OF CHILDREN. 

Miliaria. 

{Prickly Heat; Strophulus,) 

Miliaria is an affection developing at the sudariporous glands^ 
usually during the summer months. It consists of numberiess minute 
reddish papules and vesicles which appear with or after an unusual 
amount of perspiration. It is accompanied by itching and burning. 
After a few days to a week it subsides, although fresh outbreaks are 
likely if weather conditions are favorable. Evidences of scratching 
are often seen in children in connection with miliaria. 

Treatment. — A 4 per cent, solution of boric acid is soothing, or 
with infants bran baths may be used. Frequent bathing and light 
clothing are prophylactic measures with children in the summer 
months. Removal to the seashore and sea-bathing produce rapid 
amelioration and cure. 

Urticaria. 

{Nettle-rash; Hives.) 

Urticaria consists of large wheals made up of a localized area of 
edema in the papillary layer of the skin. Their centers are pale, while 
the margins are reddened. These wheals are distinctly felt by the 
hand and cause intense itching, especially at night. In the majority 
of cases urticaria results reflexly from intestinal causes. External 
irritants, such as the stinging nettle (hence one of its names), insect 
bites, etc. , may bring on a typical attack. Certain fruits, as strawberries, 
and certain kinds of drinking water produce urticaria in the predis- 
posed. A small papular urticaria, consisting of minute papules, the 
tops of which are soon scratched off, causing a drop of serum or blood 
to exude, may often be seen in early life. This form may persist for 
months and, if neglected, will eventually result in a form of papular 
eczema. This variety is in all cases the result of a prolonged faulty 
diet. Strophulus is a name sometimes given to this condition. 

Treatment — Discover the offending cause, whether external or 
dietary. Locally, baths containing bicarbonate of soda, salines for 
the bowels, and local applications of ointments containing menthol, 
camphor, or carbolic acid. Small doses of salicylate of sodium or 
aspirin will relieve the intestinal fermentation that is often the under- 
lying cause of urticaria. 

FurunculosiSc 

This is a condition in which boils occur over any part of the body, 
but especially about the head. They are due to an infection of the 
skin with pyogenic organisms. The staphylococcus pyogenes aureus 



DISEASES OF THE SKIN. 611 

is the predominating cause. They differ in their virulency and 
occasionally cause marked systemic infection. Lowered vitality 
from malnutrition, improper feeding, previous debilitating diseases, 
and skin diseases predispose to the formation of furuncles. 

They are usually small in size, multiple, and tend to rapid for- 
mation of pus. If uncared for, they rupture and the pus may in- 
oculate other abraded surfaces. The areas are painful to the touch, 
reddish or bluish-red, and discharge a yellowish, cream}^ pus. A case 
is seldom observed in the very young. Children w4th furuncles are 
restless, sleep badly, may have a low-grade temperature, cry inor- 
dinately, and lose flesh and strength. 

Treatment. Local. — A general bath in bichlorid of mercury 
(1-5,000) is first ordered; surround the furuncles in which suppuration 
has occurred with lanolin and incise and drain completely, exercising 
care not to infect neighboring regions with the pus. Remove local 
causes, if any, as scabies. 

General. — Improve by diet and fresh air the general tone, pre- 
scribing strychnia, nux vomica, or the bitter wine of iron in the anemic. 
The opsonic index may be raised by the injection of sterilized emul- 
sions following Wright's method in cases in which recurrences are 
common or in which the systemic infection is marked. 

Angioneurotic Edema. 

(Acute Circumscribed Edema.) 

This affection is characterized by circumscribed areas of edema 
which appear suddenly and have a tendency to disappear as sud- 
denly as they came. Parents of children so attacked are usually 
alarmed and ascribe the edema to some form of insect bite. Neurotic 
children with faulty digestive disturbances are especially prone, and 
recurrences are not unusi .al. Parts of the face, chest, or an extremity 
may be involved. The intestinal tract is sometimes said to be atta eked. 
We have seen the lungs involved, producng alarming symptoms which 
disappeared after a few hours. 

Treatment. — Correct the habits and mode of life if necessary. 
Rhubarb and soda mixture internally and applications of aluminum 
acetate solution (N. F.), externally, promote relief. 

Herpes Zoster. 

{The Shingles; Zoster.) 
Herpes zoster is a painful acute inflammatory affection charac- 
terized by the production of a vesicular eruption appearing over the 



612 



DISEASES OF CHILDREN. 



course of distribution of the cutaneous nerves. It is accompanied by 
an inflammation of the peripheral nerves or of the sensory gangha of 
the posterior nerve roots. 

Following a day or two of localized pain, there appear on one side 
of the body a crop of vesicles having a reddened inflamed base, which 
are seen to follow the distribution of an affected nerve. The vesicles, 




Fig. 179. — Herpes Zoster. (Walker.) 



as a rule, dry up without pustulation, unless infected by unclean chil- 
dren. Adults suffer more intensely with this affection than do children. 
It is recognized by its unilateral distribution over a nerve tract em- 
phasized by the symptom of pain. 

Treatment. — Locally, stearate of zinc as a dusting powder and a 
protective dressing are required. Small doses of phenacetin or codein 
may be required for the relief of pain. The incandescent lamp has 
given relief in some cases, as have the X-rays. 



CHAPTER XL^' . 

PARASITIC SKIN DISEASES. 

Children are more liable to this group of diseases because of their 
vulnerable, tender skin, and because even clean children are apt to 
mingle with their uncared-for schoolmates. 

Pediculosis. 

These are insects readily seen under a low-power glass. The 
head louse is from 1 to 2 mm. in length, has a head, thorax and abdo- 
men, and a sharp proboscis b}^ which it attaches itself. They are ex- 
tremely prolific, the female laying about fifty eggs, and the young being 
ready to multiply their kind after three weeks of life. The ova are en- 
veloped in a capsule and are attached to the hair. 
These are commonly known as nits. The parasite 
feeds by imbedding its proboscis in the scalp and 
sucking. Thus the intense itch- 
ing is caused. Scratching causes 
further irritation and patches of 
eczema may aj^pear. The post- 
cervical glands are enlarged in 
neglected cases, and a red line at 
the base of the hair behind is often 
FiG.lSO— Pedicu- "^'isible to confirm the diagnosis, 
lus capitis. Micro- The nits are distinguishable from .^ 
photograph. M/fer ■,■,«. i t. +i • -x- Fig. 181 .—^ its of 

Shoemaker.) dandruff scales by their position pediculus capitis. 

on the hair, their tenacity to it, W^^'' Anderson.) 
and the ability to move them up and down the hair. 

Treatment. — Cut the hair as closel}' as possible in long-standing 
cases if no great objection is made. Apply a cap made of a light 
towel soaked in coal-oil (kerosene) or pour alcohol over the scalp, be- 
ginning at the base with the head held over a basin, the parasites will 
then move on before it and are washed aw^ay. In the daytime a 
10 per cent, boric ointment is rubbed into the scalp in aggravated cases 
to allay the irritation. 

Scabies. 

{The Itch.) 
Scabies is a disease of the skin produced by the Sarcoptes scabiei 
or itch-mite which by its entrance into the skin produces burrows and 

613 





614 DISEASES OF CHILDREN. 

an eruption of vesicles, pustules, and nodules. To these are added 
the scratch-marks produced by the patient's finger-nails. Infants 
and young children are greatly annoyed by the irritation and the 
evidences of scratching are observed early. The interdigital spaces, 
the wrists and flexor surface of the forearms, the toes and inner surfaces 
of the thighs are especially affected. The whole body may be invaded 
in unrecognized or neglected cases. The prominent symptom, itching, 
is worse when the patient is in a warm bed. If the child is predisposed 
to eczema this is almost sure to supervene, and, in fact, sometimes 
masks the original cause. The disease is com- 
monly seen in dispensary children, who are 
apt to sleep with others and receive meager 
bodily attention. 

The itch-mite can with care be seen by 
the naked eye. The female is larger than the 
male. They are ovoid in shape, covered with 
hairs and have a pair of mandibles by which 
they attach themselves to the skin in burrow- 
ing. The female deposits its eggs and per- 
ishes, while the colony work their way to the 
outer skin and start burrows of their own. ^^^' 182 —The itch-mite 

( l\ €>'U/7Yl(JiTiTh I 

Treatment. — The disease is readily amen- 
able to cure if certain rules are followed faithfully. Remove all the 
clothing and bedclothes and sterilize them by boiling or baking in an 
oven. Follow a vigorous soap and hot- water bath with the applica- 
tion of sulphur ointment drachm one to the ounce. If eczema is 
present, use mild detergents, especially in the case of infants. Pow- 
dered sulphur may be used in children or a solution of styrax in the 
strength of half an ounce to the ounce of lanolin. The ointment 
selected should be applied to the whole body twice a day and two 
weekly baths taken. If there is a superadded eczema, treat the 
latter along the lines outlined for thai disease. 

Tinea Tonsurans. 

{Ringworm of the Scalp.) 

This is a contagious disease produced by a vegetable parasite, 
beginning as a mass of minute vesicles which soon affect the hair. 

The lesion consists of a rounded patch showing broken-off hairs 
(shaven beard appearance) or a partly bald area, with extension 
taking place into the periphery. The central area is more or less 
reddened with a dirty scaly margin. 

The disease is almost entirely confined to children, rarel}^ appear- 




PARASITIC SKIX DISEASES. 615 

ing after puberty; children infect each other directly or through 
articles of clothing or toys or through their pets. The patches are 
rarely seen by the physician while vesicles are present. 

The diagnosis must be made on the presence of the gnawed-off 
hairs in a rounded, reddened, scaly field in which the fungus can be 
found on the hairs. 

Examination for the Fungus. — A loosened diseased hair may be 
placed on a slide and soaked in a 10 to 20 per cent, potash solution, and 
examined for the parasite under the microscope with at least a ^- 
inch lens. 

Treatment. — Ringworm does not respond quickly to treatment. 
If depilation is first performed, a better response to antiparasitic 
remedies is obtained. The scalp should be cleansed for several days 
with green soap and water. The surrounding hair is best kept short 
or if possible shaved about the lesion. A solution of potash applied 
on a piece of gauze and rubbed in will remove any debris that remains 
after the washings. An antiparasitic ointment is now daily applied 
and a protective dressing or cap used. We have tried to our 
satisfaction applications of oil of cade and castor oil, equal parts, or 
betanaphthol one-half to one drachm to the ounce. Ten per cent, 
of aristol in flexible collodion has commended itself in children who are 
in asylums and apt to infect others. The X-rays are highly spoken 
of by dermatologists as a rapid and permanent means of cure. 

Tinea Favosa. 

Favus is a feebly contagious parasitic disease, caused by the 
Achorion Schonleinii. The lesion consists of sulphur-yellow areas on 
the scalp through which the hairs appear. The hair shaft is broken 
off, being diseased by the fungus. Closely examined, it is found that 
each hair is surrounded by a cup-shaped area; these coalescing produce 
a thick matted cake, dirty yellow in color, sometimes having a peculiar 
characteristic odor. Some pruritus is nearly always complained of. 
When the crusts are removed a scarred area with no hairs present is 
found. The diagnosis may be confirmed by an examination for the fun- 
gus under the microscope. Alow power will answer (250 diameters). 
A fragment of hair passed through a potash solution will show the 
thick broad threads. The spores seen are of many shapes and sizes. 

Treatment. — The treatment takes much time and patience, and 
at best, bald areas will occur at times. Depilation offers the safest 
and best chance of cure. This is performed after cutting short all 
the hair of the head, removing thoroughly all the crusts and debris 
with 10 per cent, boric acid ointment. The hairs are removed best 



616 



DISEASES OF CHILDREN. 



with Bulkley's adhesive, made up with burgundy pitch or by repeated 
collodion applications. The hairs are thus removed en masse. Ten 
per cent, oleate of mercury is then applied night and morning with 
frequent soap and hot-water washings. When new hairs appear the 
microscope should again be used to guard against the reappearance 
of the parasite. The X-ray may here also give good results in com- 
petent hands. 

Alopecia Areata. 

{Baldness.) 

This is a disease of the hairy scalp producing areas of baldness. 
The affection is apt to come on quite suddenly without any subjective 
symptoms. The underlying skin is white, clean, and soft. When the 
hair returns, which it does in children, it is soft, downy, and colorless 
at first. Later it slowly shows some color and the hairs themselves 




Fig. 183. — Alopecia areata. 



become firmer and of coarser texture. Schamberg believes there are 
two varieties: the parasitic and the trophoneurotic, thus explaining 
the divergence of opinion as to the etiology. 

After a variable time, sometimes months, the hair in children 
returns, although even in early life relapses are seen. 

Treatment. — Locally — many remedies have been advanced as 
serviceable. Measures which will increase the blood-supply in the 
scalp are helpful. Vigorous massage, followed by applications of 



PARASITIC SKIX DISEASES. 617 

90 per cent, alcohol has been useful in our hands. Lately the high- 
frequency current and the actinic rays have been extolled in the cure 
by dermatologists. 

Ivy Poisoning. 

The poisonous action of Rhus toxicodendron and other varieties 
of rhus (as the poison sumach) is not infrequent among children who 
are susceptible. City children because of their unfamiliarity with the 
plant are more apt to expose themselves to its venomous activity; 
when barefooted they are particularly liable to come in contact with 
it and they readily spread the poison to their face, neck and genitals. 
T^he erythematous eruption appears within a few hours and is followed 
by numerous vesicles which soon rupture and wet the surface with their 
serous exudation. Signs of inflammation, pain, heat and swelling, are 
still further ag'gravated by intense itching. About the face the 
edema may produce great disfigurement; after reaching its height the 
erythema subsides in a few days especially if restitution to the normal 
is assisted by appropriate treatment. Children and their parents 
should be taught to know the characteristics of the plant and its 
possibilities. 

Treatment. — The child should be restrained from infecting other 
parts of the body and from scratching the acutely inflamed area. 
If the eruption is seen soon after its appearance the parts should he 
copiously bathed with an alkaline solution, such as a 5 per cent, solu- 
tion of bicarbonate of soda. Then apply gauze wet with a 2 per cent, 
solution of permanganate of potash. The physician, if susceptible 
himself, should wear rubber gloves when doing the dressing. The dress- 
ing should be applied in such a way as to prevent the ruptured vesicles 
from coming in contact with the healthy skin. After the acute stage 
is passed, soothing ointments such as Lassar's paste produce good 
results. 



NDEX 



Abdomex, as aid to diagnosis, 104 

enlarged, 104 

prominent, 104 

tumors of, localized, 104 
Abdominal wall, tumors of, 105 
Abnormalities in breathing, as aid to 

diagnosis, 102 
Abscess, cerebral, 545 

ischiorectal, 584 

of brain, 545 

of Kver, 248 

of lung, 403 

peritonsillar, 377 

pulmonary, 403 

retropharyngeal, 377 

subphrenic, 406 
Absence of bones, congenital, 566 
Acetonuria, 480 
Achondroplasia, 447 

diagnosticated from cretinism, 451 
Acne, vaccine therapy in, 96 
Addison's disease, 443 
Adenie, 443 
Adenitis, acute, 444 

chronic, 445 

tuberculous, 343 

vaccine therapy in, 95 ' 
Adenoids, 375 

etiology, 375 

examination, 376 

symptomatology, 375 

treatment, 376, 377 
Administration of drugs, 76 

of food for infants, 184 
Adolescence, 39 
Adrenals, disorders of, 442 

hemorrhage into, 443 
Aerotherapy, 82, 83 
Albuminuria, cyclic, 479 

functional, 479 

physiologic, 479 
Alopecia areata, 616 
Amaurotic family idioc}', 558 
Amboceptor, 66 
Amebic dysentery, 233 
Amygdalitis, acute, 372 
Amyloid liver, 247 
Anemia, 426 

pernicious, 428, 431 

secondary, 426 

simple, 426 

splenic, 431 

von Jacksch's, 430, 431 



Anemias, table of, 431 

treatment of, 433 
Anesthesia, 574 

chl:)roform, 574 

gas-ether, 575 

preparation for, 575 
Anesthetic, choice of, 574 
Angina, Vincent's, 373 
Angioneurotic edema, 525, 611 
Animal parasites, 235 

found in childhood, 235 
Ankylostomum duodenale, 240 
Anopheles mosquito, 330, 331 
Anterior poliomyelitis, 317 
Antibody, 66 
Antigen, 66 

Antitoxin, diphtheria, 279, 280 
Anuria, 475 
Anus, fissure of, 585 

imperforate, 563 

malformations of, 563 

prolapse of, 586 

stenosis of, 563 
Aortic obstruction, 417 

regurgitation, 417 
Aphthae, 204 

Bednar's, 205 
Apoplexy, meningeal, during birth, 9 
Appendicitis, 577 

abscess formation, 579 

diagnosis, 579 

etiology, 577 

examination, 578 

pathology, 577 

prognosis, 579 

suppurative form, 578 

symptomatology, 578 

treatment, 579 
Appendix, of infant, 33 
Arnold sterilizer, 183, 184 
Arthritides, infectious, 328 
Arthritis, diagnosed from rheumatism, 
326 

tuberculous, 330 
Arthritis deformans, 329 
Arthrogr^-posis, 521, and see Tetany 
Artificial respiration, 12 
Articular rheumatism, acute, 324 
Ascaris lumbricoides, 236 
Ascites, 584 

chylous, 584 
Asphyxia, during birth, 10, 13 

artificial respiration in, 12 



619 



620 



INDEX. 



Asphyxia, direct insufflation in, 11 

preventive treatment of, 11 
Aspirating syringe, 401 
Aspiration of pleural cavity, technic of, 

56 
Assimilation, infants differ in power of, 
154 

most efficient in early infancy, 154 
Asthma, bronchial, 388 

thymic, 382 
Ataxia, Friedreich's, 535 

hereditary, 535 
Atelectasis, congenital, 12 
Athrepsia, 464, and see Marasmus 
Atrophic paralysis, acute, 317 
Atrophy, idiopathic muscular, 537 

infantile, 464, and see Marasmus 
Attitude, typical, of normal infant, 29 
Auroscope, electric, 594 
Auscultation of infants and children, 46, 
47 

Babcock milk test, 190 
Babinski's reflex, 47, 314 
Bacteriolytic system, 66, 67, 68 
Balanitis, 498 
Baldness, 616 
Barlow's disease, 462 
Basedow's disease, 446 
Basket-crib for premature infant, 3 
Bathing, in infancy, 26 
Baths, artificial Nauheim, 87 

bed, 84 

brine, 85 

carbonic acid, 87 

hot, 85 

hot air, 85 

mustard, 86 

sheet, 84 

soothing, 86 

special, 85 

sponge, 84 

warm, 85 
Bed baths, 84 
Bednar's aphthae, 205 
Beef juice, to make, 177 
Beef-tea, to make, 176 
Bell's palsy, 530 

Biliary ducts, inflammation of, 246 
Birth, injuries during, 6 

palsies, 8 
Bladder, calculus in, 506 

diseases of, 505 

ectopia of, 565 

extrophy of, 565 

inflammation of, 505 

of infant, 33 

spasm of, 506 
Blennorrhea, urogenital, 499 
Blepharitis, 595 
Blood, 423 

cells, red, 424 
nucleated, 424 



Blood cells, number of, 424 

corpuscles, white, 424 

corpuscular element of, 423 

counts, 59, 60 

diseases of, 423 

examination of, 59 

in feces, 53 

in urine, 478 

plates, 426 

pressure, 407 

smears, method of making, 61 
Blue disease, 408 
Boiler, double, 170 
Boils, 610 
Bone, caries of, 359 

congenital absence of, 566 

fractures of, during birth, 7 

injuries to, during birth, 7 

swollen, 107 

tuberculosis of, 359 
Bowels, regularity of, in infancy, 27 
Boys, height and weight of, 38 
Brain, abscess of, 545 

diseases of, 543 

tumors of, 546 
Branchial cysts, congenital, 561 

fistula?, 561 
Breasts, preparation of, for lactation, 
120 

type of, preferable for wet-nursing, 
127, 128 
Breast-feeding, 119, and see Nursing 

importance of, 119 

intervals of, 120 

management of, 120 

not possible, 126 

preparation for, 120 

regularity of, 120 

scanty supply of milk, 121 
Breast milk, examination of, 123 

for premature infants, 3 

reaction of, 124 

specific gravity of, 124 

pumps, 125 

secretions, 112 

composition of, 112 
properties of, 112 
Breathing, abnormalities in, as aid to 
diagnosis, 102 

exercises in, 96 

mouth, in nasal obstruction, 102 
Breck feeder for premature infants, 4 
Bright's disease, acute, 481 
Brine bath, 85 
Bronchial asthma, 388 

stenosis, 103 
Bronchiectasis, 404 
Bronchitis, acute, 384 
diagnosis, 385 
etiology, 384 
physical signs, 384 
prognosis, 385 
symptomatology, 384 



INDEX. 



621 



Bronchitis, acute, treatment, 385 
capillary, ^589 
chronic, 386 
Bronchopneumonia, acute, 389 

aerotherapy in, 393 

clinical forms of, 391 

complicating the infectious dis- 
eases, 392 

complications of, 392 

course of, 393 

diet in, 393 

differential diagnosis of, 392 

hydrotherapy in, 394 

local applications in, 394 

medication in, 394 

pathology of, 389 

physical signs of, 390 

prognosis of, 393 

symptomatology of, 389, 391 

treatment of, 393 

tuberculous, 347 
Buhl's disease, 18 
Buttermilk, 179 

Calculi, renal, 477 

vesical, 506 
Calmette test for tuberculosis, 65, 349 
Calorie feeding, 181 
Calx chlorata, as a disinfectant, 339 
Cancrum oris, 208 
Cap, ice, 84 

Capillary bronchitis, 389 
Caput succedaneum, 6 
Carbohydrates, forms of, used in infant 
feeding, 131 

of cereals, 140 
Carbolic acid, as a disinfectant, 339 
Carbonic acid baths, 87 
Cardiac disorders, functional, 418 
Caries of bone, 359 

of spine, 360 
Catalysers, 193 
Catarrhal fever, acute, 297 
Central paralysis, during birth, 9 
Cephalhematoma, 6 
Cereal gruels, percentage, 159, 161 
Cereals, 139 

preparation of, 170 

properties of, 139 

carbohydrates of, 140 
Cerebral palsies, infantile, 547 

paralysis, 508 
Cerebrospinal fever, 312 

fluid, examination of, 53 
Cestodes, 235, 238 
Chalazion, 596 
Changes in the features, as a sign of 

illness, 74 
Chapin's cream dipper, 159 

infant urinal, 470 

tongue depressor, 368, 369 
Chest, abnormal shape of, 103 

as aid to diagnosis, 103 



Chest- wall, tumors of, 103 
Chickenpox, 271 
Child, height of, 38 

mental growth of, 33 

moral growth of, 39 

relative measurements of, 32, 33, 
38 

weight of, 38 
Childhood, diet during later, 200 

growth during, 36 

pulse in, 45 

relation of neutrophiles to lympho- 
cytes in, 62 

respirations in, 41 
Children, auscultation of, 46, 47 

mensuration of, 48 

percussion of, 47 

rectal examination of, 48 
Children's hospitals, diet lists for, 198 
Chlorid of lime, as a disinfectant, 339 
Chlorin, as a disinfectant, 338 
Chlorofom anesthesia, 574 
Chlorosis, 427, 431 
Choked disk, 599 
Cholera infantum, 229 
Chondrodystrophy, fetal, 447 
Chorea, 511 

complications, 513 
course, 513 
diagnosis, 513 
etiology, 511 
forms of, 514 
pathology, 512 
prognosis, 513 
symptoms, 512 
treatment, 513 

Huntington's 514 

insaniens, 514 

major, 514 

minor, 511 

Sydenham's, 511 
Chvostek's symptom in tetany, 523 
Chylous ascites, 584 
Circumcision, 577 
Cirrhosis of Hver, 248 
Claw hand, 107 
Cleft palate, 561 
Clothing, in infancy, 25 
Clubbed fingers, 107 
Club-foot, 566 
CoUc, 222 

Collapse, pulmonary, 386 
Colles' law, 302 
Colon, dilatation of, congenital, 229 

flushing the, 88, 89, 90 

irrigation of the, 88, 89, 90 
Colostrum, 112 
Complement, 66 
Compresses, 85 
Condensed milk, 138 
mixtures, 178 
Congenital absence of bones, 566 

atelectasis, 12 



622 



INDEX. 



Congenital branchial cysts, 561 

dilatation of colon, 229 

dislocation of hip, 565 

heart disease, 408 

infantile stridor, 382 

laryngeal stridor, 382 

malformations and deformities, 560 

rachitis, 462 
Congestion of liver, 247 
Conjunctivitis, acute, 595 

chronic, 596 

diphtheritic, 596 

granular, 596 

of the newly-born, 21 
Constipation, 231 
Convulsions, 509 

description of the symptom-com- 
plex, 510 

differential diagnosis, 511 

etiology, 510 

prognosis, 510 

treatment, 511 
Cow's milk, 132 

composition of, 132 

influence of breed on, 132 

influence of breed on composition 
of, 132 

one, 132 
Coxalgia, 361 
Cream, 136 

centrifugal, 136 

gravity, 136 
Cream dipper, Chapin's, 159 
Creches, diet lists for, 199 
Cresol, as a disinfectant, 339 
Cretinism, 449 

differential diagnosis, 451, 557 

etiology, 449 

prognosis, 453 

symptomatology, 450 

treatment, 454 
Croup, 276 

catarrhal, 378 

false, 378 . 

spasmodic, 378 

diagnosticated from laryngismus 
stridulus, 381 

tent, 380 
Croupous pneumonia, 396, and s q 

Lobar pneumonia 
Cryptorchidism, 502 
Culex mosquito, 330, 331 
Cyanosis, 408 

in premature infants, 5 
Cystitis, 505 

vaccine therapy in, 95 
Cysts, branchial, congential, 561 

Dactylitis, 107 

syphilitic, 307 

tuberculous, 359 
Day nurseries, diet lists for, 199 
Dead-born infant, 13 



Dead, from infectious diseases, care of, 

340 
Death, fetal, 13 
Deformities, congenital, 560 

exercises for developing children 
with, 97 

of head, 6 
Delayed growth as aid to diagnosis, 105 
Deming's percentage milk modifier, 169 
Dentition, 34 

first, 34 

delayed, 34, 102 

disturbances of, 35 
Dermatitis, acute exfoliative, 604 

diagnosticated from scarlet fever, 
260 

exfoliativa neonatorum, 602 
Development of digestive tract, 113 

of infant, 30 
Dextrinized gruel, to make, 175 
Diabetes insipidus, 476 

melhtus, 468 
Diacetonuria, 480 

Diagnosis, suggestive scheme for, 100 
Diarrhea, infectious, 223 

summer, 223 
Diet during later childhood, 200 

during second year, 195 

during third year, 197 

from third to sixth year, 198 
Dietary after the sixth year, 201 

during second year, 195 

from 12 to 18 months, 195 

from 18 to 24 months, 195 

from 2 to 3 years, 197 

from 3 to 6 years, 198 
Diet-lists, for children's hospitals, 198 

for day nurseries and creches, 199 
Digestive organs, comparative anatomy 
and physiology, 114 

system, diseases of, 202 

tract, development of, 113 
diseases of, 210 
Dilatation of colon, congenital, 229 

of stomach, 215 
Diphtheria, 274 

antitoxin, 279, 280 

complications, 278 

conjunctival, 278 

differential diagnosis, 275, 276 

diagnosis of, 51 

etiology, 274 

extubation, 285 

feeding of intubated cases, 286 

general treatment, 279 

intubation, 281 

laryngeal, 276 

local treatment, 280 

nasal, 277 

pathology, 274 

pharyngeal, 275 

prognosis, 279 

prophylaxis, 279 



IXDEX. 



623 



Diphtheria, serum treatment, 280 

symptomatology, 274 

tonsillar, 275 

tracheotomy, 286 

treatment, 279 
Diphtheritic paralysis, 529 
Diplegia, spastic, 547 
Diplopia, 599 
Discharges, state of, as a sign of illness, 

74 
Disinfectants, 337 

aerial, 337 

chemical, 337 
Disinfection, 337 

of discharges, 340 

of room, 340 
Dislocation of hip, congenital, 565 
Dispensaries for infants' foods, 189 
Disseminated sclerosis, 534 
Dosage, 76, 77 

in vaccine therapy, 96 
Double boiler, 170 
Drugs, administration, 76 

dosage of, 76, 77 

elimination of, in milk, 122 

frequently used in pediatric prac- 
tice, 77 
Duchenne's paralysis, during birth, 8 
Ductless glands, diseases of, 439 
Duke's disease, diagnosed from scarlet 

fever, 261 
Dysentery, amebic, 233 
Dyspepsia, acute, 211 
Dvsphagia, false, 102 

true, 102 
Dyspnea, expiratory, 103 

inspiratory, 102 

mixed, 103 
Dystrophy, muscular, 537 

Ear, 590 

diseases of, 590 

speculum, 590, 591, 594 
Eclampsia infantum, 509, and see 

Convulsions 
Ectopia of bladder, 565 
Eczema, 605 

acute, treatment, 607 
general, 607 
local, 608 

chronic, 606 
treatment, 609 

crustosum, 606 

diagnosis, 606 

etiological factors, 605 

erythematous, 605 

madidans, 606 

papular, 605 

prognosis, 607 

pustular, 605 

rubrum, 606 

subacute, treatment, 608 

subvarieties, 606 



Eczema, symptomatology, 606 

varieties, 605 

vesicular, 605 
Edema, acute circumscribed, 525, 611 
* angioneurotic, 525, 611 

of glottis, 379 
Eggs, 140 

Ehrlich's preparation for syphilis, 309 
Emphysema, 387 

acute, 387 
Empyema, 399 

exploratory puncture, 400 

symptomatology, 399 

treatment, 401 

vaccine therapy in, 95 
Encephalitis, acute, 545 
Encephalocele, 569, 571 
Endocarditis, acute, 410 
diagnosis, 412 
etiology, 410 
pathology, 410 
prognosis, 412 
symptomatology, 411 
treatment, 412 

malignant, 411 

septic, 411 

ulcerative, 411 

vaccine therapy in, 95 
Enemata, nutrient, 92 
Enlargement, general, 107 
Enteralgia, 222 
Enteroclysis, 88, 89, 90 
Enterocolitis, acute, 225 
Enuresis, 493 

treatment, 495 
Eosinophiles, 425 
Eosinophiha, 63, 423, 426 
Epidemic cerebrospinal meningitis, 312 

hemoglobinuria, 17 

paralysis in children, 322 

parotitis, 291 . 

Epilepsy, 516 

diagnosis, 517 

etiology, 516 

grand mal, 516 

petit mal, 516 

prognosis, 517 

symptomatology, 516 

treatment, 517 
Epistaxis, 106, 366 
Erb's myotonic reaction, 524 

paralysis during birth, 8 

symptom, in tetany, 523 
Erysipelas, 334 

etiology, 334 

prognosis, 336 

symptomatology, 334 

treatment, 336 
Erythema multiforme, 604 

scarlatiniforme, diag nosticated 
from scarlet fever, 259 
Erythemata, diagnosed from scarlet 
fever, 259 



624 



INDEX. 



Erythrocytes, 423, 424 
Esophagitis, corrosive, 210 
Esophagus, congenital occlusion of, 
210 

inflammation of, see Esophagitis 

malformations of, 563 
Essential paralysis of children, 317 
Examination of sick child, 41 

blank for, 42 
Examinations, special, 51 
Exanthemata, 249 

table of, 273 
Exercise and fresh air in infancy, 26 
Exercises, brjeathing, 96 

for developing children with de- 
formities, 97 

for increasing respiratory capacity, 
^ 98 

resistant, 96 
Exophthalmic goiter, 446 
Exophthalmos, 599 

Exploratory puncture in empyema, 400 
Expression of face, 101 
Extremities, as aid to diagnosis, 106 

rigidity of, 106 

spastic j 106, 
Extrophy of bladder, 565 
Extubation, 285 

Exudates and transudates differenti- 
ated, 58 

examination of, 51 
Evaporated milk, 138 
Eye, affections of, diagnostic hints 
regarding, 598 
diagnostic significance of, 598 

diagnostic hints regarding affection 
of, 598 

diseases of, 595 

foreign bodies in, 595 

test for tuberculosis, 65 

Face, as aid to diagnosis, 101 

expression of, 101 
Facial paralysis, 530 
during birth, 8 
Fat in milk, to decrease amount of, 191 
to increase amount of, 191 
percentages of, in different portions 
of milk, 157 
Fats, forms of, used in infant feeding, 

131 
Fatty degeneration of the newly-born, 
18 
hver, 247 
Favus, 615 
Features, changes in, as a sign of illness, 

74 
Feces, and see Stools 
blood in, 53 
examination of, 52 
ova, in 53 
Feeblemindedness, 554, and see Idiocy 
Feeders for premature infants, 4 



Feeding, and see Infant Feeding, 
Nutrition 

among the poor, 189 

calorie, 181 

directions, outline of, 165 

forced, 90 

in hot weather, 186 

in typhoid fever, 296 

infant, chemical and biological 
standards in, 116 

laboratory, 179 

mixed, 126 

of intubated cases, 286 

of premature infants, 3, 4 

on large scale, to make, 190 

practical, 155 

prepared at feeding station, 192 

rectal, 92 

station, feedings prepared at, 192 

substitute, see Substitute Feeding 

table, suggestive, 168 

utensils, care of, 185 

when away from home, 188 

when travelling, 187 
Fetal chondrodystrophy, 447 

death, 13 
Fever, acute catarrhal, 297 
Fingers, clubbed, 107 

webbed, 569, 570 
Fissure of anus, 585 

of mouth, 101 

of tongue, 101 
Fistulse, branchial, 561 
Fontanels, abnormal, 100 
Food, adaptation of, to infant, 171 

administration of, 184 

care of, in infant feeding, 182 

dispensaries, 189 

essential unity of, 110 

for acutely ill infants, 175 

for healthy infants, 166 

for infants, administration of, 184 

for infants of feeble constitution, 
174 

for infants previously badly fed, 
172 

for infants who fail to thrive on 
fresh milk, 177 

of first nutritive period, 110 

specialized, 112 
Foot, club-, 566 

Foot-drop, in anterior poliomyelitis, 319 
Forced feeding, 90 
Foreign bodies in eye, 595 

in nose, 367 

in respiratory tract, 405 
Formaldehyd, as a disinfectant, 337 

generators, 337 
Formalin, as a disinfectant, 339 
Fourth disease, diagnosticated from 

scarlet fever, 261 
Fractures during birth, 7 
Freeman's pasteurizer, 183 



INDEX. 



625 



Fresh air, in infancy, 26 

in treatment of disease, 82 

Friedreich's ataxia, 535 

Functional cardiac disorders, 418 

Furunculosis, 610 

vaccine therapy in, 95 

Gangrene of lung, 403 
Gas-ether anesthesia, 575 
Gastric catarrh, acute, 211 

contents, examination of, 52 

indigestion, acute, 211 

ulcer, 212 
Gastritis, acute, 211 

chronic, 214 
Gastroenteritis, acute, 223 
Gastrointestinal indigestion, chronic, 

227 
Gavage, 90 

danger of, in premature infants, 4 
Genital organs, diseases of, 497 
German measles, 254 
Girls, height and weight of, 39 
Glands of infant, 33 
Glomerulonephritis, acute, 481 
Glossitis, desquamative, 202 
Glottis, edema of, 379 
Goiter, exophthalmic, 446 
Gonitis tuberculosa, 363 
Grand mal, 516 
Graves' disease, 446 
Growth, delayed, as aid to diagnosis, 
105 

during childhood, 36 

mental, of child, 39 

moral, of child, 39 

of infant, 29 
Gruels, cereal, percentage, 159, 161, 162 

dextrinized, to make, 175 

directions for making, 170 
Gums, bleeding, 102 

spongv, 102 

swollen, 102 

Hand, abnormal, 107 

claw, 107 
HareUp, 560 
Head, as aid to diagnosis, 100 

deformity of, 6 

fontanels, abnormal, 100 

injury to, during birth, 6 

motion of, abnormal, 100 

of infant, 30 

position of, abnormal, 100 

shape of, abnormal, 100 

size of, abnormal, 100 

tumors about, 100 
Headaches, 518 
Heart, the, 407 

beats, 408 

disease, congenital, 408 

diseases of the, 407 

functional disorders of, 418 
40 



Heart, location of valves, 415 

palpitation of, 419 

valvular disease of, 414 
aortic, 417 
mitral, 416 
prognosis in, 418 
tricuspid, 418 
Height of child, 38 
Hematuria, 478 

Hematoma of sternocleidomastoid, 7 
Hemic murmurs, 419 
Hemiplegia, spastic, 547 
Hemoglobin, estimation of, 59 
Hemoglobinometer, 59 
. Hemoglobinuria, 478 

epidemic, 17 
Hemolytic system, 66, 67, 68 
Hemophilia, 437 
Hemorrhages, as aid to diagnosis, 105 

causes of, general, 105 
special, 106 

from nose, 106 

from rectum, 106 

into adrenals, 443 

of new-born, 106 

of stomach, 106 

spontaneous, in the newly-born, 23 

umbihcal, 15 
Henoch's purpura, 436 
Hereditary ataxia, 535 

course, 537 

differential diagnosis, 536 

etiology, 535 

pathology, 535 

prognosis, 537 

symptomatology, 536 

treatment, 537 
Hernia, 575 

diagnosis, 576 

etiology, 575 

symptomatology, 575 

treatment, 576 

lunbilical, 17 

Pisek's dressing for, 16 
Herpes zoster, 611 
Hip, congenital dislocation of, 565 

tuberculous disease of, 361 
Hip- joint disease, 361 
Hirschsprung's disease, 229 
History of sick child, 41 

blank for, 42 
Hives, 610 

Hodgkins' disease, 443 
Hook worm, 240 
Hoover breast pump, 125 
Hordeolum, 597 
Hot-air bath, 85 
Hot baths, 85 
Hot pack, 85, 86 

Hot weather, infant feeding in, 186 
Huntington's chorea, 514 
Hutchinson's teeth, 36, 310 
Hydrencephalocele, 570, 571 



626 



INDEX. 



Hydrocele, 502 

congenital, 502 

encysted, of the cord, 502 

infantile, 502 

of tunica vaginalis, 502 
Hydrocephalus, 551 

acquired, 551 

classification of, 551 

congenital, 551 

diagnosis, 552 

etiology, 551 

prognosis, 553 

symptomatology, 551 

treatment, 553 
Hydronephrosis, 491 
Hydrotherapy, 84 
Hygiene of infancy, 25 
Hyperleukocytosis, 423, 426 
Hyperphonia, 526 

Hypertrophy of pylorus, congenital, 216 
Hypodermoclysis, 89 
Hypospadias, 564 
Hypostatic pneumonia, 395 
Hysteria, 514 

etiology, 514 

prognosis, 515 

symptomatology, 514 

treatment, 515 

Ice cap, 84 

poultice, 85 
Icterus in premature infants, 5 

neonatorum, 18 
Ichthyosis, 600 
Idiocy, 554 

etiology, 554 

prognosis, 555 

symptomatology, 554 

treatment, 556 
Idiocy, amaurotic family, 558 

Mongolian, 556 
Imbecility, 554, and see Idiocy 
Immune body, 66 
Immunization, reaction of, 92 
Impetigo contagiosa, 603 
Inability to walk, 106 
Incontinence of urine, 493 
Incubator, for premature infants, 2, 5 
Indican, test for, 57 
Indicanuria, 479 
Indigestion, gastric, acute, 211 

gastro-intestinal, chronic, 227 
Infancy, assimilation in, 154 

bathing in, 26 

clothing in, 25 

exercise and fresh air, in 26 

general habits in, 27 

habits of sleep in, 27 

hygiene of, 25 

pulse in, 45 

regularity of bowels, in, 27 

respirations in, 41 

signs of illness in, 73 



Infancy, urine in, 470 
Infant, and see Newly-born 
a mammary fetus. 111 
acutely ill, food for, 175 
adaptation of food to, 171 
appendix of, 33 
attitude of normal, 29 
auscultation of, 46, 47 
bladder of, 33 
dead-born, 13 
development of, 30 
difference of, in digestive and 

assimilative efficiency, 154 
glands of, 33 
growth of, 29 
head of, 30 
healthy, food for, 166 
intestines of, 33 
lacrimal glands of, 33 
length of, 29 
liver of, 33 
loss of weight during first few 

days, 28 
mensuration of, 48 
muscles of, 33 
nucleated red cells in, 62 
nutrition of, 108, 117 
of feeble constitution, foods for, 174 
pancreas of, 33 
percussion of, 47 

premature, see Premature infants 
previously badly fed, food for, 172 
rectal examination of, 48 
relative measurements of, 31 
salivary glands of, 33 
sebaceous glands of, 33 
shape of, 30 
skull of, 30, 31 
spine of, 33 
stillborn, 13 
stomach of, 33 
teeth of, 34 
tendency of, to adapt themselves 

to their food, 153 
testicles of, 33 
thymus of, 33 
viscera of, 33 
weighing of, 28, 186 

importance of, 185 
weight and development of, 28 

chart, 187 
who fail to thrive on fresh milk, ' 
foods for, 177 
Infant-feeding, 108, 117 
among the poor, 189 
carbohydrates used in, 131 
care of food, 182 

of utensils, 185 
chemical and biological standards 

in, 116 
directions for mother or nurse, 182 
education of mother necessary, 

182 



I 



INDEX. 



627 



Infant-feeding, fats used in, 131 

fundamental errors in, 146 

how to interpret results, 185 

in hot weather, 186 

methods of modifying milk for, 149 

mineral matter used in, 131 

percentage milk mixtures in, 155 

practical, 155 
basis of, 155 

proteins used in, 130 

scientific, rise and development of, 
145 

when away from home, 188 

when traveling, 187 
Infant-foods, administration of, 184 

dispensaries, 189 

proprietary, 141 

classification of, 141 
composition of, 142 
Infantile atrophy, 464, and see Ma- 
rasmus 

cerebral palsies, 547 

paralysis, 317 

scurvy, 462 

stridor, congenital, 382 
Infantilism, 449 

Brissaud type, 449 

diagnosed from cretinism, 451 

Lorain type, 449 
Infection, how carried, 339 
Infectious arthri tides, 328 

diarrhea, 223 

diseases, 249 

bronchopneumonia complicat- 
ing, 392 
disinfection in, 339 
of the newly-born, 14 
sick-room in, 339 
Inflammation of biliary ducts, 246 

of portal vein, 246 
Influenza, 297 

definition, 297 

diagnosis, 300 

etiology, 297 

incubation, 297 

pathology, 297 

symptomatology, 298 

treatment, 300 
Inguinal region, as aid to diagnosis, 105 

enlargement of, 105 

swellings in, differential diagnosis 
of, 503 

tumors of, 105 
Injuries during birth, 6 

to bone, 7 

to head, 6 

to muscle, 7 
Insomnia, 519 
Inspection of sick child, 41 
Insufflation, direct, in asphyxia, 11 
Intestines, of infants, 33 

tumors of, 104 
Intubation, 281 



Intussusception, 580 

diagnosis, 581 

etiology, 580 

prognosis, 581 

symptomatology, 580 

treatment, 581 
Inunctions for premature infants, 5 
Inunction test for tuberculosis, 65, 349 
Invagination, intestinal, 580 
Irritability of temper, as a sign of 

illness, 73 
Ischemic paralysis, Volkman's, 509 
Ischiorectal abscess, 584 
Itch, the, 613 
Itch-mite, 614 
Ivy poisoning, 617 

Jaundice, 244, and see Icterus 
Joints, swollen, 107 

tuberculosis of, 359 
Jugular bulb infection, 593 

Keratitis, 597 
Kernig's sign, 314 

method of eliciting, 45, 46 
Kidney, amyloid, 486 

congestion of, 480 
chronic, 480 

disorders of, 470 

formation of, 474 

large white, 486 

passive hyperemia of, 480 

tumors of, 104, 490 

waxy, 486 
Kilmer belt for pertussis, 290 
Knee, tuberculous disease of, 363 
Koplik's spots, 250 

Laboratory feeding, 179 
Lacrimal glands of infant, 33 
La Grippe, 297 
Laryngeal stenosis, 103 

stridor, congenital, 382 
Laryngismus stridulus, 381 
Laryngitis, acute, 378 

diagnosticated from laryngismus 
stridulus, 381 

diphtheritic, diagnosticated from 
acute laryngitis, 379 

spasmodic, 378 

submucous, 379 
Larynx, new growths of, 383 

papilloma of, 383 
Lavage, 88 
Length of infant, 29 

premature infant, 3 
Leptomeningitis, acute, 543 
Leukemia, 428 

lymphatic, 429, 431 

splenomyelogenous, 429, 431 
Leukocytes, 423, 424 

number of, 425 
Leukocytosis, 423, 426 



628 



INDEX. 



Leukopenia, 423, 426 
Limp, walking with, 106 
Lip, hare-, 560 
Lips, enlarged, 101 
Liver, 243 

abscess of, 248 

amyloid, 247 

cirrhosis of, 248 

congestion of, 247 

diseases of, 243 

enlarged, 104 

examination of, 243 

fatty, 247 
Liver of infant, 33 
Lobar pneumonia, 396 

complications, 396 

diagnosis, 396 

etiology, 396 

pathology, 396 

physical signs, 396 

prognosis, 397 

symptomatology, 396 

treatment, 397 

vaccine therapy in, 95 
Lobular pneumonia, 389 
Logi's method of breathing, 98 
Lumbar puncture, in cerebrospinal 
meningitis, 314, 317 

technic of, 55 
Lungs, abscess of, 403 

diseases of, 384 

gangrene of, 403 
Lymphadenoma, 443 
Lymphocytes, 424 

in childhood, 62 
Lymphocytosis, 423, 426 

MacEwen's sign, 314 
Macroglossia, 101 
Malaria, 330 

diagnosis of, 63 

differential diagnosis, 333 

etiology, 330 

pathology, 331 

prophylaxis, 333 

symptomatology, 332 

treatment, 333 
Malformations, congenital, 560 
v~ of anus, 563 

of esophagus, 563 

of rectum, 563 
Mammary secretions, and see Milk 

comparative, 115 
Marasmus, 464 

course, 466 

diet in, 467 

etiology, 464 

medication, 468 

pathology, 464 

prognosis, 466 

symptomatology, 465 

treatment, 466 
Mast cells, 425 



Mastitis of the newly born, 22 
Mastoiditis, 592 

vaccine therapy in, 96 
Masturbation, 501 
Measles, 249 

complications, 251 
definition, 249 
eruption, 251 
etiology, 249 
exanthem, 251 
fever, 251 
German, 254 
' incubation, 250 
Koplik's spots, 250 
pathology, 250 
prodromal stage, 250 
prognosis, 253 
prophylaxis, 253 
sequelae, 251 
treatment, 253 
variations, 251 
Measurements, physical, 37 
relative of infant, 31 
of child, 31, 32, 38 
Meat broths, to make, 176 
Megaloblast, 423, 424 
Melena neonatorum, 23 
Meningeal apoplexy, during birth, 9 
Meningitis, 543 

diagnosis, 544 
etiology, 543 
leptomeningitis, 543 
pachymeningitis, 543 
symptomatology, 543 
treatment, 544 
epidemic cerebrospinal, 312 
complications, 315 
differential diagnosis, 315 
etiology, 312 

lumbar puncture in, 314, 317 
pathology, 312 
prognosis, 315 
serum treatment, 316 
symptomatology, 313 
treatment, 316 
tuberculous, 352 
Meningocele, 569, 571 
Mensuration of infants and children, 48 
Mental growth of a child, 39 
Mercurial salts, as disinfectants, 338 
Microblast, 423 
Microcephalus, 553 
Microcyte, 424 
Migraine, 518 
Miliaria, 610 
Miliary tuberculosis, acute, 351 

of lungs, 347 
Milk, and see Mammary secretions 

and gruel mixtures, percentage 

composition of, 162, 163 
and water percentages, 160 
approximate home modification of, 
192 



IXDEX. 



629 



jSIilk, bacteriology of, 133 
bottled, 135 
certified, 135 
commissions, 135 
condensed, 138 
cows', 132 
crust, 603 

elimination of drugs in, 122 
evaporated, 138 
fat in, to decrease, 191, 

to increase, 191 
grocer}', 134 
human, normal, 112 
inspected, 135 
market, 134 

composition of, 136 
microscopical appearance of, 137 
mixtures, percentage, in infant 

feeding, 155 
modification of, approximate, 192 
modified, 148 

classification of methods em- 
ployed, 149 
effects of various methods em- 
ployed, 150 
modifier, 169 

mother's, disagrees with in j ant, 122 
drugs eliminated in, 122 
insufficient, 121 
one cow's, 132 
pasteurized, 135 
peptonized, 178 
percentages of fat, in different 

portions of, 157 
sanitary, 135 

production of, 134 
sterilized, 135 
test, Babcock's, 190 
top, 156 

percentage of food element in, 
160 
whole, approximate home modifi- 
cation of, 192 
Mineral matters used in infant feeding, 

131 
Mitral obstruction, 416 

regurgitation, 416 ^ 
Modified milk, 148 

approximate, 192 
classification of methods, 149 
effects of various methods, 150 
for premature infants, 4 
Moles, 601 
Mongolian idiocy, 556 

diagnosticated from cretinism, 451, 
557 
Moral growth of child, 39 
Morbilli, 249, and see Measles 
Morbus coxae, 361 
Moro test for tuberculosis, 65, 349 
Mosquitoes, 330, 331 
Motion, disturbances of, 106 
Mouth, as acid to diagnosis, ICl 



Mouth breathing in nasal obstruction, 
102 

diseases of, 202 

fissures of, 101 

inflammation of, see Stomatitis 

open, 101 

putrid sore, 207 

ulcerations of, 101 

white, 205 
Movements, purposeless involuntarv, 

107 
Multiple neuritis, 528 

sclerosis, 534 
Mumps, 291 

complications, 292 

differential diagnosis, 292 

etiology, 291 

pathology, 291 

prognosis, 292 

symptomatology, 292 

treatment, 292 
Murmurs, hemic, 419 
Muscles injuries to, during birth, 7 

of infants, 34 

paralysis of, 509 
Muscular atrophy, idiopathic, 537 

dvstroph}', 537 
Mustard bath, 86 
Myelitis, 532 

diagnosis, 534 

etiology, 532 

pathology, 532 

prognosis, 534 

symptomatology, 532 

treatment, 534 
Myelocytes, 425 
Myocarditis, 413 
Myopathy, primary, 537 

complications, 541 

differential diagnosis, 541 

etiology, 537 

pathology, 538 

symtomatology, 539 

treatment, 541 

types of, 537 
Myotonia congenita, 524 
Myotonic reaction, of Erb, 524 
Myxedema, 449, and see Cretinism 

Nasal obstruction, mouth breathing in, 

102 
Nasopharyngeal toilet, the. 87 
Nauheim baths, artificial, 87 
Neck, as aid to diagnosis, 101 

tumors about, 101 
Nematodes, 235 
Nephritis, 481 
acute, 481 

complications, 484 

definition, 481 

diagnosis, 484 

etiology, 481 

pathology, 482 



630 



INDEX. 



Nephritis, acute, prognosis, 484 
symptomatology, 482 
synonyms, 481 
treatment, 485 
desquamative, 481 
diffuse, 481 
exudative, 481 
glomerulo-, 481 
parenchymatous, 481 
tubular," 481 
chronic, 486 

complications, 487 
definition, 486 

diagnosed from cretinism, 453 
diagnosis, 487 
etiology, 486 
pathology, 486 
prognosis, 488 
symptomatology, 487 
synonyms, 486 
treatment, 488 
diffuse, 486 
interstitial, 486 
parenchymatous, 486 
Nerve paralysis, 509 
Nerves, peripheral, diseases of, 528 
Nervous diseases, general, 507 

system, diseases of, 507 
Nettle-rash, 610 
Neuritis, multiple, 528 
course, 529 
definition, 528 
diagnosis, 528 
etiology, 528 
prognosis, 529 
symptomatology, 528 
pathology, 528 
treatment, 529 
optic, 599 
Neutrophiles in childhood, 62 
Nevi, 601 

New growths of larynx, 383 
Newly-born, and see Infant 

acute infectious diseases of the, 14 
conjunctivitis of the, 21 
dimensions of, 31 
diseases of the, 14 
fatty degeneration of the, 18 
hemorrhages of, 106 
icterus of, 18 
mastitis of, 22 
sepsis of the, 14 

spontaneous hemorrhages in the, 23 
tetanus of, 20 
Night terrors, 520 
Nipple shield, 126 

Noguchi's method of examining cere- 
brospinal fluid, 54 
test for syphilis, 65, 68, 69, 71 
Noma, 208 
Normoblast, 423, 424 
Nose, bleeding from, 106, 366 
foreign bodies in, 367 



Nucleated red cells in infants, 62 

Nursery, the 26 

Nursing and see Breast-feeding 

bottle, 183 

contraindications for, 126 

not possible, 126 
Nutrition, and see Feeding 

difference of infants in capacity for, 
154 

diseases of, 456 

of infant, 108, 117 

of premature infants, 3 
Nutritional disorders, 456 
Nutritive periods of life, 109 
Nystagmus, 599 

Occlusion of esophagus, congenital, 210 
Ophthalmia neonatorum, 21 
Opsonic index, 93 
Opsonins, 93 
Optic neuritis, 599 
Otitis, 591 

vaccine therapy in, 96 
Otoscopy. 590 
Ova in feces, 53 
Oxyuris vermicularis, 235 

Pachymeningitis, 543 
Packs, hot, 85 
Palate, cleft, 561 
Palpation of sick child, 44 
Palpitation of heart, 419 
Palsies, birth, 8 

classification of, 548 
infantile cerebral, 547 
classification, 548 
diagnosis, 550 
etiology, 547 
pathology, 547 
symptoms, 549 
treatment, 550 
Palsy, Bell's, 530 
cerebral, 320 
peripheral, 320 
spinal, 320 
Paludism, 330 
Pancreas of infant, 33 
PapilUtis, 599 
Papilloma of larynx, 383 
Paralysis, 106, 508 

acute atrophic, 317 

wasting, 317 
central, during birth, 9 
cerebral, 508 
diphtheritic, 529 
Duchenne's, during birth, 8 
epidemic, in children, 322 
Erb's, during birth, 8 
essential, of children, 317 
facial, 530 

during birth, 8 
general characteristics of the va- 
rious types, 508 



INDEX. 



631 



Paralysis, in general, 508 

infantile, 317 

ischemic, Volkmann's, 509 

muscle, 509 

nerve, 509 

postdiphtheritic, 278 

pseudo-, 106, 509 

spinal, 509 

upper-arm, during birth, 8 
Paramyoclonus multiplex. 524 
Paraphimosis, 497 
Paraplegia, spastic, 508, 547 
Parasites, animal, 235 

found in childhood, 235 
Parasitic protozoa, 235 

skin diseases, 613 
Parotitis, epidemic, 291 
Pasteurized milk, 135 
Pasteurizer, 183, 184 
Patellar reflex, 46 
Pavor nocturnus, 520 
Pediculosis, 613 
Pediculus capitis, 613 
Pemphigus neonatorum, 602 
Peptonized milk, 178 
Percentage cereal gruels, 159, 161 

milk mixtures, in infant feeding. 155 
Percussion of infants and children, 47 
Pericarditis, 420 

diagnosis, 421 

etiology, 420 

pathology, 420 

physical signs, 420 

prognosis, 421 

symptomatology, 420 

treatment, 421 
Pericardium, diseases of, 420 
Perinephritis, 490 
Peripheral nerves, diseases of, 528 
Peritonitis, acute, 581 
diagnosis, 583 
in early life, 582 
in the new-born, 581 
prognosis, 583 
symptomatology, 582 
treatment, 584 

gonorrheal, 583 

pneumococcic, 583 

tuberculous, 355 
Peritonsillar abscess, 377 
Perleche, 205 
Pertussis, 287 

aerotherapy in, 289 

complications, 288 

course, 289 

diet in, 291 

drugs for, 289 

etiologv, 287 

Kilmer belt for, 290 

pathology, 287 

primary stage of, 287 

prognosis, 289 

recession of symptoms, 288 



Pertussis, spasmodic stage, 288 

symptomatology, 287 

treatment, 289 
Petit mal, 516 
Pharyngeal stenosis, 102 

tonsil, hypertrophy of, 375 
Pharyngitis, acute, 371 

in infants, 369 
treatment, 371 
Phimosis, 497 
Photophobia, 598 
Physical measurements, 37 
Pioscope, 124 
Pisek's dressing for umbilical hernia, 16 

reversible stethoscope, 47 
Plaques, blood, 426 
Plates, blood-, 426 

Platform scale, for weighing baby, 28 
Pleura, diseases of, 384 
Pleural cavitv, aspiration of, technic of, 

56 ' 
Pleurisy, 397 

dry, 397 

serofibrinous, 397 
pathology, 397 
physical signs, 398 
prognosis, 398 
svmtomatologv, 398 
treatment, 398 
Pneumonia, catarrhal, 389 

croupous, 396, and see Lobar 
pneumonia 

hypostatic, 395 

lobar, 396, and see Lobar pneu- 
monia 

lobular, 389 

vaccine therapy in, 95 
Pneumothorax, 402 
Poikilocytosis, 423 
Poliomyelitis, anterior, 317 

definition, 317 

diagnosis, 320 

etiology, 317 

pathology, 318 

prognosis, 321 

symptomatology, 318 

treatment, 321 ' 
Polynuclears, 424 
Polynucleosis, 423 
Polypus, rectal, 585 
Polyuria, 476 

Portal vein, inflammation of, 246 
Postdiphtheritic paralysis, 278 
Pott's disease, 360 

cervical, 360 

dorsal, 360 

lumbar, 360, 362 
Poultice, ice, 85 
Practical feeding, 155 

basis of, 155 
Premature infants, breast milk for, 3 

care of, 1 

cyanosis in, 5 



632 



INDEX. 



Premature infants, danger of gavage 
in, 4 

death rate of, 1 

factors prejudicial to life of, 1 

feeders for, 4 

feeding of, 3, 4 

icterus in, 5 

incubators for, 2, 5 

inunctions for, 5 

length of, 3 

management and care of, 1 

modified milk for, 4 

nutrition of, 3 

subnormal temperature of, 1, 2 

temperature of, 1, 2 

weight of, 3, 4 
Prickly heat, 610 
Primary myopathy, 537 
Prof eta's law, 302 
Prolapse of anus, 586 

of rectum, 586 
Proprietary infant foods, 141 

classification of, 141 

composition of, 142 
Proteins, forms of, used in infant 

feeding, 130 
Protozoa, parasitic, 235 
Pseudodysphagia, 102 
Pseudoleukemia, 443 

of infants, 430, 431 
Pseudo-paralysis, 106, 509 
Psoriasis, 609 
Psychotherapy, 82 
Ptosis, 598 
Pulmonary abscess, 403 

collapse, 386 

gangrene, 403 

tuberculosis, 349 
Pulse, in infancy and childhood, 45 
Puncture, lumbar, 55 

subdural, 55 
Purpura, 434 

fulminans, 436 

hemorrhagica, 435 

Henoch's, 436 

Schonlein's, 436 

simplex, 434 
Putrid sore mouth, 207 
Pyelitis, 488 

definition, 488 

diagnosis, 489 

etiology, 488 

pathology, 488 

prognosis, 489 

symptomatology, 489 

thread reaction in, 58 

treatment, 489 

vaccine therapy in, 95 
Pylephlebitis, suppurative, 246 
Pyloric spasm, 216 
Pylorus, hypertrophy of, congenital, 216 

stenosis of, 216 



Quinsy, sore throat, 377 

Rachitic spine, 361 
Rachitis, 456 

antenatal, 462 

congenital 462 

course, 460 

diagnosis, 460 

deformities in, 459, 461 

dietetic treatment of, 461 

etiology, 456 

hygienic treatment of, 461 

medication in, 461 

pathology of, 456 

prognosis of, 460 

prophylaxis, 460 

symptomatology of, 457 

treatment of, 460 
Radius, congenital absence of, 568 
Reaction of immunization, 92 
Rectal examination of infants and 
children, 48 

feeding, 92 

polypus, 585 

syringe for infants, 232 
Rectum, hemorrhages from, 106 

malformations of, 563 

obstruction of, 563 

prolapse of, 586 
Renal calculi, 477 
Resistant exercises, 96 
Respiratory capacity, exercises for in- 
creasing, 98 

tract, foreign bodies in, 405 
upper, diseases of the, 366 
Respiration, artificial, methods of, 12 

in infancy and childhood, 41 
Restless sleep, as a sign of illness, 74 
Retropharyngeal abscess, 377 
Reversible stethoscope, 47 
Rheumatic fever, 324 
Rheumatism, acute articular, 324 

complications, 325 

differential diagnosis, 326 

etiology, 324 

drugs for, 327 

prognosis, 326 

prophylaxis, 327 

symptomatology, 325 

treatment, 327 
Rheumatoids, 329 
Rhinitis, acute, 366 
Rhus poisoning, 617 
Rickets, 456, and see Rachitis 

diagnosed from cretinism, 453 
Rigid extremities, 106 
Ringworm of scalp, 614 

of tongue, 202 
Ritter's disease, 602 
Roentgen rays, 59 
Rotheln, 254 
Round worm, 236 



INDEX. 



633 



Rubella, scarlatiniform, diagnosticated 

from scarlet fever, 261 
Rubeola, 249, 254, and see Measles 

Salivary glands of infant, 33 

Salt-rheum, 605 

Salvarsan, 309 

Sarcoma, 587 

Scabies, 613 

Scalp, ringworm of, 614 

Scarlatina, 255, and see Scarlet fever 

Scarlet fever, 255 

anginal form, 256 

complications of, 264 

definition, 255 

desquamation, 256, 258 

desquamative stage, 262 

diet in, 263 

differential diagnosis, 259 

eruptive stage, 262 

etiology, 255 

incubation, 255 

pathology, 255 

predesquamative stage, 262 

preemptive stage of, 262 

prognosis, 262 

prophylaxis, 263 

rash, 257 

sequelae of, 264 

serum treatment of, 265 

sick-room quarantine, 263 

simple form, 255 

symptomatic treatment, 264 

s^Tnptomatologv, 255 

treatment, 263 ^ 

vaccine therapy in, 94 
Schonlein's purpura, 436 
Sclerosis, disseminated, 534 

multiple, 534 
Scorbutus, 462 

aggravated cases, 463 

course, 463 

dietetic treatment of, 464 

diagnosis of, 463 

etiology of, 462 

mild cases, 462 

pathology of, 462 

prognosis of, 463 

prophylaxis of, 464 

s^^mptomatology of, 462 

treatment of, 464 
Scurvy, infantile 462 
Sebaceous glands of infant, 34 
Seborrhea capitis, 603 
Secretions, breast, 112 
Sepsis of the newh-born, 14 
Septicemia, vaccine therap}- in. 95 
Septicopyemia, vaccine therapy in, 95 
Serum, method of collecting for tests, 70 

rashes, diagnosed from scarlet 
fever, 261 
Sheet baths, 84 
Shingles, 611 



Sick child, examination of, 41 
blank for, 42 

history of, 41 

blank for, 42 

inspection of, 41 

palpation of, 44 

to take temperature of, 43 
Sick-room, in infectious diseases, 339 
Signs of illness in infancy, 73 
Sinus thrombosis, infective cerebral, 593 
Skin, diseases of, 600 

parasitic, 613 
Skin test for tuberculosis, 64, 349 
Skull of infant, 30, 31 
Sleep, amount required, 519 

habits of, in infancy, 27 

restless, as a sign of illness, 74 
Smallpox, 265 

complications, 267 

definition, 265 

etiology, 266 

exanthem, 266 

incubation, 266 

prodromal stage, 266 

pathology, 266 

prognosis, 268 

prophylaxis, 269 

sequelae, 267 

symptomatologv, 266 

treatment, 269 ^ 

variations, 267 
Soor, 205 
Soothing bath, 86 
Sore mouth, putrid, 207 
Spasm, pyloric, 216 

vesical, 506 
Spastic diplegia, 547 

extremities, 106 

hemiplegia, 547 

paraplegia, 508, 547 
Special examinations, 51 
Speciahzed foods, 112 
Speculum, ear, 590, 591 
Spina bifida, 572 
Spinal cord, diseases of, 532 

inflammation of, see Myelitis 
Spinal paralysis, 509 
Spine, caries of, 360 

of infants, 33 

rachitic, 361 
Spleen, chronic passive congestion of, 
442 

diseases of, 442 

enlarged, 104 

enlargement of, 442 

inflammation of, 442 
SpondyUtis, 360 
Sponge baths, 84 
Spontaneous hemorrhages in the newlv- 

born, 23 
Sprue, 205 

Sputum, examination of, 52 
Squint, 597 



634 



INDEX. 



Stammering, 526 
Status lymphaticus, 441 
Steam., as a disinfectant, 338 
Stenosis, bronchial, 103 

laryngeal, 103 

of pylorus, 216 

pharyngeal, 102 

tracheal, 103 
Sterilized milk, 135 
Sterilizer, for infant food, 183, 184 
Sternocleidomastoid, hematoma of, 7 
Stethoscope, Pisek's reversible, 47 
Stillborn infant, 13 
Still's disease, 330 
Stomacace, 207 
Stomach, dilatation of, 215 

hemorrhages from, 106 

inflammation of, see Gastritis 

of different milk secreting animals, 
114 

of infant, 33 

tumors of, 104 

ulcer of, 212 

washing, 88 
Stomatitis, aphthous, 204 

catharral, 203 

follicular, 204 

gangrenous, 208 

herpetic, 204 

maculofibrinous, 204 

mycotic, 205 

parasitic, 205 

simple, 203 

ulcerative, 207 

vesicular, 204 
Stools, 219 

character of, as a sign of illness, 75 

examination of, 185, 220 

of artifically fed infants, 220 
Strabismus, 597, 599 
Stridor, congenital infantile, 382 

laryngeal, 382 
Strippings, 123 
Strophulus, 610 
Stuttering, 526 

St. Vitus' dance, 511, and see Chorea 
Stye, 597 

Subdural puncture, technic of, 55 
Subphrenic abscess, 406 
Substitute feeding, 129 

difficulties of, 129 

material used in, 132 

principles of, 129 
Suggestion, in treatment of disease, 

82 
Sulphurous acid, as a disinfectant, 

338 
Summer complaint, 223 

diarrhea, 223 
Supernumerary thumb, 570 
Surgical diseases, 574 
Sutures of skull, 30 
Swallowing, as aid to diagnosis, 102 



Swellings in inguinal region, differential 
diagnosis of, 503 
of extremities, 107 
Sydenham's chorea, 511 
Syndactylism, 569 
SyphiHs, 301 

acquired, 311 

congenital, 301, and see Syphilis, 

hereditary 
definition, 301 

diagnosed from tuberculosis, 307 
Ehrlich's preparation for, 309 
Salvarsan in, 309 
hereditary, 301 
Colles' law, 302 
definition, 301 
diagnosis, 306 

method of transmission, 301 
pathology, 302 
prognosis, 308 
symptomatology, 304 
treatment, 308 
late hereditary, 309 

Hutchinson's teeth, 310 
treatment, 311 
Wasserman test for, 71, 301 
Syphilitic dactylitis, 307 
Syringe, aspirating, 401 
rectal, for infants, 232 

Talipes, 566 

acquired, 567 

calcaneus, 568 

congenital, 566 

equinus, 567 

treatment, 568 

valgus, 568 

varus, 567 
Tape worms, 238 

armed, 239 

beef, 239 

pork, 239 
Teeth, abnormalities, 102 

Hutchinson's, 36, 310 

of infant, 34 

temporary, care of, 35 

permanent, 35 
Temper, irritability of, as a sign of 

illness, 73 
Temperature of premature infant, 1 

to take, 43 
Tenia mediocanellata, 238, 239 

saginata, 238, 239 

soUum, 238, 239 
Testicle, undescended, 502 
Testicles of infant, 33 
Tetanilla, 521, and see Tetany 
Tetanus neonatorum, 20 
Tetany, 521 

differential diagnosis, 523 

etiology, 521 

prognosis, 523 

symptomatology, 521 



INDEX. 



635 



Tetany, treatment, 523 

Tetter, 605 

Therapeutics, general, 76 

Therapy, vaccine, 92, 93 

Thermos vacuum bottle, 188 

Thomsen's disease, 521 

Thoracentesis, 401 

Thoracic tuberculosis, 346 

Thread reaction in pyelitis, 58 

Thread worms, 235 

Throat examination of, in infants, 368, 

370 
Thrombosis, sinus, infective cerebral, 

593 
Thrush, 205 

Thumb, supernumerarv, 570 
Thvmic asthma, 382 
Thymus, 439 

enlargement of, 439 

of infant, 33 
Tics, 525 

differential diagnosis, 526 

treatment, 526 
Tinea favosa, 615 

tonsurans, 614 
Toes, webbed, 569 
Tongue depressors, Chapin's, 368, 369 

enlarged, 101 

fissures of, 101 

geographic, 202 

inflammation of, see Glossitis 

ringworm of, 202 

ulcers of, 101 
Tongue-tie, 560 

Tonsillar hypertrophy, chronic, 374 
Tonsil, pharyngeal, hypertrophy of, 375 
Tonsillitis, acute follicular, 372 

in infants, 369 
treatment, 371 

ulcero membranous, 373 
Top milk, 156 
Tracheal stenosis, 103 
Trachoma, 596 

Transudates, examination of, 58 
Traveling, infant feeding when, 187 
Tracheotomy, 286 
Trichina spiralis, 241 
Tricuspid regurgitation, 418 
Trousseau's symptom, in tetany, 523 
TubercuKn test, 64, 348, 349 
Tuberculosis, 341 

acute mihary, 351 

differential diagnosis, 352 
etiology, 351 

bone, 359 

and joint tuberculosis, 359 

diagnosed from syphilis, 307 

disease of hip, 361 
of knee, 363 

etiology, 341 

incipient, diagnosis of, 347 

joint, 359 

miliary, of lungs, 347 



Tuberculosis, of vertebrae, 360 

diagnosis, 360 

treatment, 361 
prophylaxis, 363 
pulmonary, 349 

acute form, 349 
etiology, 349 
physical signs, 350 

chronic, 350 
course, 351 

subacute form, 349 
etiology, 349 
physical signs, 350 
tests for, 64, 65, 348, 349 

Calmette test, 65, 349 

eye test, 65, 349 

inunction tests, 349 

Moro test, 349 

skin test, 348, 349 

von Pirquet test, 349 
thoracic, 346 

diagnosis, 347 
pulmonary lesions, 347 
treatment in general, 363 
tuberculin test in, 64, 348, 349 
Tuberculous adenitis, 343 

course, 345 

diagnosis, 345 

prognosis, 345 

symptomatology, 343 

treatment, 345 
arthritis, 330 
bronchopneumonia, 347 
dactylitis, 359 
disease of hip, 361 

treatment, 362 
disease of knee, 363 

treatment, 363 
meningitis, 352 

course, 355 

diagnosis, 355 

etiology, 353 

prognosis, 355 

symptomatology, 353 

treatment, 355 
peritonitis, 355 

ascitic form, 356, 357 

caseating form, 356 

diagnosis, 357 

fibrous form, 356 

miliary form, 356 

symptomatology, 357 

treatment, 359 

ulcerative form, 356 
Tumors about head, 100 
about neck, 101 
malignant, in children, 587 

diagnosis, 588 

treatment, 589 
of abdomen, localized, 104 
of abdominal wall, 105 
of brain, 546 
of chest wall, 103 



636 



INDEX. 



Tumors, of inguinal region, 105 

of intestines, 104 

of kidney, 104, 490 

of stomach, 104 
Typhoid fever, 293 

drugs in, 297 

etiology, 293 

feeding in, 296 

hydrotherapy in, 296 

laboratory tests for, 295 

pathology, 293 

prophylaxis, 295 

symptomatology, 294 

temperature curve in, 294 

treatment, 295, 296 

vaccine therapy in, 94 

Widal test for, 63 

Ulcer, gastric, 212 
Ulcerations of mouth, 101 

of tongue, 101 
Umbilical hemorrhages, 15 

hernia, 17 

Pisek's dressing for, 16 

region, abnormalities of, 105 

vegetations, 16 
Uncinaria duodenalis, 240 
Undescended testicle, 502 
Upper-arm paralysis during birth, 8 
Urethritis, 498 , 
Urine, acetone in,, 480 

albumin in, 479, and see Albumin- 
uria 

blood in, 478 

character of, 471 

as a sign of illness, 75 

diacetic acid in, 480 

disorders of, 470 

examination of, 56 

excess of, 476 

hemoglobin in, 478 

incontinence of, 493 

indican in, 57, 479 

in infancy, 470 

quantity of, 56 

suppression of, 475, and see Anuria 

to collect, 470 
Urinal, for infants, 470 
Urogenital blennorrhea, 499 
Uropoietic system diseases of, 470 
Urticaria, 610 
Uvula, elongated, 209 

Vaccination, 269 

description of normal course, 270 

method of, 270 

value of, 269 

variations and complications, 271 

when to vaccinate, 270 
Vaccine therapy, 92, 93 

dosage in, 96 
Vaccinia, 269 



Vaginitis, specific, vaccine therapy in, 

95 
Valves of heart, location of, 415 
Vavular disease of heart, chronic, 414 

aortic, 417 

mitral, 416 

tricuspid, 418 
Varicella, 271 

Variola, 265, and see Smallpox 
Varioloid, 267 
Vegetations, umbilical, 16 
Vertebrae, tuberculosis of, 360 
Vesical calculus, 506 

spasm, 506 
Vincent's angina, 373 
Viscera of infant, 33 
Viscogen, 138 
Vomiting, as a sign of illness, 74 

cycHc, 218 

periodic, 218 

recurrent, 218 
Volkman's ischemic paralysis, 509 
Von Jaksch's anemia, 430, 431 
Von Pirquet test for tuberculosis, 64, 
349 
^ Vulvo-vaginitis, 499 

treatment, 500 

vaccine treatment, 500 

Walk, inability to, 106 

with limp, 106 
Warm baths, 85 

Wasserman test for syphilis, 65, 68, 69, 
71 
' Wasting paralysis, acute, 317 

Water, in treatment of disease, 84 
, Weaning and mixed feeding, 126 
Webbed fingers, 569 

Weighing infant, 28, 186 
importance of, 185 
Weight chart, 49 

for infant, 187 
of child, 38 
of infant, 28 _ 
of premature infant, 3, 4 
Wet-nurse, selection of, 127 
Whey, directions for making, 173 

and cream mixtures, 173 
White mouth, 205 
swelling, 363 
Whooping-cough, 287 
Widal test for typhoid fever, 63 
Winckel's disease, 17 
Worms, hook, 240 
round, 236 
tape, 238 
thread, 235 

Xerodermia, 600 
X-rays, use of, 59 

Zoster, 611 



oa ^ 1^1' 



One copy del. to Cat. Div. 



CC.1 s *"' 



LIBRARY OF CONGRESS 



022 216 180 



